For a month in advance, the people who filled the courtroom had been told by the press that they would see the man who was a greedy enemy of society; but they had come to see the man who had invented Rearden Metal.

He stood up, when the judges called upon him to do so. He wore a grey suit, he had pale blue eyes and blond hair; it was not the colours that made his figure seem icily implacable, it was the fact that the suit had an expensive simplicity seldom flaunted these days, that it belonged in the sternly luxurious office of a rich corporation, that his bearing came from a civilised era and clashed with the place around him.

The crowd knew from the newspapers that he represented the evil of ruthless wealth; and - as they praised the virtue of chastity, then ran to see any movie that displayed a half-naked female on its posters - so they came to see him; evil, at least, did not have the stale hopelessness of a bromide which none believed and none dared to challenge. They looked at him without admiration - admiration was a feeling they had lost the capacity to experience, long ago; they looked with curiosity and with a dim sense of defiance against those who had told them that it was their duty to hate him.

A few years ago, they would have jeered at his air of self-confident wealth. But today, there was a slate-grey sky in the windows of the courtroom, which promised the first snowstorm of a long, hard winter; the last of the country's oil was vanishing, and the coal mines were not able to keep up with the hysterical scramble for winter supplies. The crowd in the courtroom remembered that this was the case which had cost them the services of Ken Danagger. There were rumours that the output of the Danagger Coal Company had fallen perceptibly within one month; the newspapers said that it was merely a matter of readjustment while Danagger's cousin was reorganising the company he had taken over. Last week, the front pages had carried the story of a catastrophe on the site of a housing project under construction: defective steel girders had collapsed, killing four workmen; the newspapers had not mentioned, but the crowd knew, that the girders had come from Orren Boyle's Associated Steel.

They sat in the courtroom in heavy silence and they looked at the tall, grey figure, not with hope - they were losing the capacity to hope - but with an impassive neutrality spiked by a faint question mark; the question mark was placed over all the pious slogans they had heard for years.

The newspapers had snarled that the cause of the country's troubles, as this case demonstrated, was the selfish greed of rich industrialists; that it was men like Hank Rearden who were to blame for the shrinking diet, the falling temperature and the cracking roofs in the homes of the nation; that if it had not been for men who broke regulations and hampered the government's plans, prosperity would have been achieved long ago; and that a man like Hank Rearden was prompted by nothing but the profit motive. This last was stated without explanation or elaboration, as if the words "profit motive" were the self-evident brand of ultimate evil.

The crowd remembered that these same newspapers, less than two years ago, had screamed that the production of Rearden Metal should be forbidden, because its producer was endangering people's lives for the sake of his greed; they remembered that the man in grey had ridden in the cab of the first engine to run over a track of his own Metal; and that he was now on trial for the greedy crime of withholding from the public a load of the Metal which it had been his greedy crime to offer in the public market.

According to the procedure established by directives, cases of this kind were not tried by a jury, but by a panel of three judges appointed by the Bureau of Economic Planning and National Resources; the procedure, the directives had stated, was to be informal and democratic. The judge's bench had been removed from the old Philadelphia courtroom for this occasion, and replaced by a table on a wooden platform; it gave the room an atmosphere suggesting the kind of meeting where a presiding body puts something over on a mentally retarded membership.

One of the judges, acting as prosecutor, had read the charges.
"You may now offer whatever plea you wish to make in your own defence," he announced. Facing the platform, his voice inflectionless and peculiarly clear, Hank Rearden answered:
"I have no defence."
"Do you --" The judge stumbled; he had not expected it to be that easy. "Do you throw yourself upon the mercy of this court?"
"I do not recognise this court's right to try me."
"What?"
"I do not recognise this court's right to try me."
"But, Mr. Rearden, this is the legally appointed court to try this particular category of crime."
"I do not recognise my action as a crime."
"But you have admitted that you have broken our regulations controlling the sale of your Metal."
"I do not recognise your right to control the sale of my Metal."
"Is it necessary for me to point out that your recognition was not required?"
"No. I am fully aware of it and I am acting accordingly."

He noted the stillness of the room. By the rules of the complicated pretence which all those people played for one another's benefit, they should have considered his stand as incomprehensible folly; there should have been rustles of astonishment and derision; there were none; they sat still; they understood.
"Do you mean that you are refusing to obey the law?" asked the judge.
"No. I am complying with the law - to the letter. Your law holds that my life, my work and my property may be disposed of without my consent. Very well, you may now dispose of me without my participation in the matter. I will not play the part of defending myself, where no defence is possible, and I will not simulate the illusion of dealing with a tribunal of justice."
"But, Mr. Rearden, the law provides specifically that you are to be given an opportunity to present your side of the case and to defend yourself."
"A prisoner brought to trial can defend himself only if there is an objective principle of justice recognised by his judges, a principle upholding his rights, which they may not violate and which he can invoke. The law, by which you are trying me, holds that there are no principles, that I have no rights and that you may do with me whatever you please. Very well. Do it." "Mr. Rearden, the law which you are denouncing is based on the highest principle - the principle of the public good."
"Who is the public? What does it hold as its good? There was a time when men believed that 'the good' was a concept to be defined by a code of moral values and that no man had the right to seek his good through the violation of the rights of another. If it is now believed that my fellow men may sacrifice me in any manner they please for the sake of whatever they deem to e their own good, if they believe that they may seize my property simply because they need it - well, so does any burglar. There is only this difference: the burglar does not ask me to sanction his act."

A group of seats at the side of the courtroom was reserved for the prominent visitors who had come from New York to witness the trial. Dagny sat motionless and her face showed nothing but a solemn attention, the attention of listening with the knowledge that the flow of his words would determine the course of her life. Eddie Willers sat beside her. James Taggart had not come. Paul Larkin sat hunched forward, his face thrust out, pointed like an animal's muzzle, sharpened by a look of fear now turning into malicious hatred. Mr. Mowen, who sat beside him, was a man of greater innocence and smaller understanding; his fear was of a simpler nature; he listened in bewildered indignation and he whispered to Larkin, "Good God, now he's done it! Now he'll convince the whole country that all businessmen are enemies of the public good!"

"Are we to understand," asked the judge, "that you hold your own interests above the interests of the public?"
"I hold that such a question can never arise except in a society of cannibals."
"What ... do you mean?"
"I hold that there is no clash of interests among men who do not demand the unearned and do not practice human sacrifices."
"Are we to understand that if the public deems it necessary to curtail your profits, you do not recognise its right to do so?"
"Why, yes, I do. The public may curtail my profits any time it wishes - by refusing to buy my product."
"We are speaking of ... other methods."
"Any other method of curtailing profits is the method of looters - and I recognise it as such."
"Mr. Rearden, this is hardly the way to defend yourself."
"I said that I would not defend myself."
"But this is unheard of! Do you realise the gravity of the charge against you?"
"I do not care to consider it."
"Do you realise the possible consequences of your stand?"
"Fully."
"It is the opinion of this court that the facts presented by the prosecution seem to warrant no leniency. The penalty which this court has the power to impose on you is extremely severe."
"Go ahead."
"I beg your pardon?"
"Impose it."
The three judges looked at one another. Then their spokesman turned back to Rearden. "This is unprecedented," he said.
"It is completely irregular," said the second judge. "The law requires you submit to a plea in your own defence. Your only alternative is to state for the record that you throw yourself upon the mercy of the court."
"I do not."
"But you have to."
"Do you mean that what you expect from me is some sort of voluntary action?"
"Yes."
"I volunteer nothing."
"But the law demands that the defendant's side be represented on the record."
"Do you mean that you need my help to make this procedure legal?"
"Well, no ... yes ... that is, to complete the form."
"I will not help you."
The third and youngest judge, who had acted as prosecutor snapped impatiently, "This is ridiculous and unfair! Do you want to let it look as if a man of your prominence had been railroaded without a --" He cut himself off short. Somebody at the back of the courtroom emitted a long whistle.
"I want," said Rearden gravely, "to let the nature of this procedure appear exactly for what it is. If you need my help to disguise it - I will not help you."
"But we are giving you a chance to defend yourself - and it is you who are rejecting it."
"I will not help you to pretend that I have a chance. I will not help you to preserve an appearance of righteousness where rights are not recognised. I will not help you to preserve an appearance of rationality by entering a debate in which a gun is the final argument. I will not help you to pretend that you are administering justice."
"But the law compels you to volunteer a defence!"
There was laughter at the back of the courtroom.
"That is the flaw in your theory, gentlemen," said Rearden gravely, "and I will not help you out of it. If you choose to deal with men by means of compulsion, do so. But you will discover that you need the voluntary co-operation of your victims, in many more ways than you can see at present. And your victims should discover that it is their own volition - which you cannot force - that makes you possible. I choose to be consistent and I will obey you in the manner you demand. Whatever you wish me to do, I will do it at the point of a gun. If you sentence me to jail, you will have to send armed men to carry me there - I will not volunteer to move. If you fine me, you will have to seize my property to collect the fine - I will not volunteer to pay it. If you believe that you have the right to force me - use your guns openly. I will not help you to disguise the nature of your action."
The eldest judge leaned forward across the table and his voice became suavely derisive: "You speak as if you were fighting for some sort of principle, Mr. Rearden, but what you're actually fighting for is only your property, isn't it?"
"Yes, of course. I am fighting for my property. Do you know the kind of principle that represents?"
"You pose as a champion of freedom, but it's only the freedom to make money that you're after."
"Yes, of course. All I want is the freedom to make money. Do you know what that freedom implies?"
"Surely, Mr. Rearden, you wouldn't want your attitude to be misunderstood. You wouldn't want to give support to the widespread impression that you are a man devoid of social conscience, who feels no concern for the welfare of his fellows and works for nothing but his own profit."
"I work for nothing but my own profit. I earn it."


There was a gasp, not of indignation, but of astonishment, in the crowd behind him and silence from the judges he faced. He went on calmly:
"No, I do not want my attitude to be misunderstood. I shall be glad to state it for the record. I am in full agreement with the facts of everything said about me in the newspapers - with the facts, but not with the evaluation. I work for nothing but my own profit - which I make by selling a product they need to men who are willing and able to buy it. I do not produce it for their benefit at the expense of mine, and they do not buy it for my benefit at the expense of theirs; I do not sacrifice my interests to them nor do they sacrifice theirs to me; we deal as equals by mutual consent to mutual advantage - and I am proud of every penny that I have earned in this manner. I am rich and I am proud of every penny I own. I made my money by my own effort, in free exchange and through the voluntary consent of every man I dealt with - voluntary consent of those who employed me when I started, the voluntary consent of those who work for me now, the voluntary consent of those who buy my product. I shall answer all the questions you are afraid to ask me openly. Do I wish to pay my workers more than their services are worth to me? I do not. Do I wish to sell my product for less than my customers are willing to pay me? I do not. Do I wish to sell it at a loss or give it away? I do not. If this is evil, do whatever you please about me, according to whatever standards you hold. These are mine. I am earning my own living, as every honest man must. I refuse to accept as guilt the fact of my own existence and the fact that I must work in order to support it. I refuse to accept as guilt the fact that I am able to do it better than most people - the fact that my work is of greater value than the work of my neighbours and that more men are willing to pay me. I refuse to apologise for my ability - I refuse to apologise for my success - I refuse to apologise for my money. If this is evil, make the most of it. If this is what the public finds harmful to its interests, let the public destroy me. This is my code - and I will accept no other. I could say to you that I have done more good for my fellow men than you can ever hope to accomplish - but I will not say it, because I do not seek the good of others as a sanction for my right to exist, nor do I seek the good of others as a sanction for my right to exist, nor do I recognise the good of others as a justification for their seizure of my property or their destruction of my life. I will not say that the good of others was the purpose of my work - my own good was my purpose, and I despise the man who surrenders his. I could say to you that you do not serve the public good - that nobody's good can be achieved at the price of human sacrifices - that when you violate the rights of one man, you have violated the right of all, and a public of rightless creatures is doomed to destruction. I could say to you that you will and can achieve nothing but universal devastation - as any looter must, when he runs out of victims. I could say it, but I won't. It is not your particular policy that I challenge, but your moral premise. If it were true that men could achieve their good by means of turning some men into sacrificial animals, and I were asked to immolate myself for the sake of creatures who wanted to survive at the price of my blood, if I were asked to serve the interests of society apart from, above and against my own - I would refuse. I would reject it as the most contemptible evil, I would fight it with every power I possess, I would fight the whole of mankind, if one minute were all I could last before I were murdered, I would fight in the full confidence of the justice of my battle and of a living being's right to exist. Let there be no misunderstanding about me. If it is now the belief of my fellow men, who call themselves the public, that their good requires victims, then I say: The public good be damned, I will have no part of it!"

The crowd burst into applause.

Rearden whirled around, more startled than his judges. He saw face that laughed in violent excitement, and faces that pleaded for help; he saw their silent despair breaking out into the open; he saw the same anger and indignation as his own, finding release in the wild defiance of their cheering; he saw the looks of admiration and the looks of hope. There were also the face of loose-mouthed young men and maliciously unkempt females, the kind who led the booing in newsreel theatres at any appearance of a businessman of the screen; they did not attempt a counter-demonstration; they were silent.

As he looked at the crowd, people saw in his face what the threats of the judges had not been able to evoke: the first sign of emotion. It was a few moments before they heard the furious beating of a gavel upon the table and one of the judges yelling:
" -- or I shall have the courtroom cleared!"
As he turned back to the table, Rearden's eyes moved over the visitor's section. His glance paused on Dagny, a pause perceptible only to her, as if he were saying: It works. She would have appeared calm except that her eyes seemed to have become too large for her face. Eddie Willers was smiling the kind of smile that is a man's substitute for breaking into tears. Mr. Mowen looked stupefied. Paul Larkin was staring at the floor. There was no expression on Bertram Scudder's face - or on his wife, Lillian's. She sat at the end of a row, her legs crossed, a mink stole slanting from her right shoulder to her left hip; she looked at Rearden, not moving.

In the complex violence of all the things he felt, he had time to recognise a touch of regret and longing: there was a face he had hoped to see, had looked for from the start of the session, had wanted to be present more than any other face around him. But Francisco d'Anconia had not come.
"Mr Rearden," said the eldest judge, smiling affably, reproachfully and spreading his arms, "it is regrettable that you should have misunderstood us so completely. That's the trouble - that businessmen refuse to approach us in a spirit of trust and friendship. They seem to imagine that we are their enemies. Why do you speak of human sacrifices? What made you go to such an extreme? We have no intention of seizing your property or destroying your life. We do not seek to harm your interests. We are fully aware of your distinguished achievements. Our purpose is only to balance social pressures and do justice to all. This hearing is really intended, not as a trial, but as a friendly discussion aimed at mutual understanding and co-operation."
"I do not co-operate at the point of a gun."
"Why speak of guns? This matter is not serious enough to warrant such references. We are fully aware that the guilt in this case lies chiefly with Mr. Kenneth Danagger, who instigated this infringement of the law, who exerted pressure upon you and who confessed his guilt by disappearing his guilt by disappearing in order to escape trial."
"No. We did it by equal, mutual, voluntary agreement."
"Mr. Rearden," said the second judge, "you may not share some of our ideas, but when all is said and done, we're all working for the same cause. For the good of the people. We realise that you were prompted to disregard legal technicalities by the critical situation of the coal mines and the crucial importance of fuel to the public welfare."
"No. I was prompted by my own profit and my own interests. What effect it had on the coal mines and the public welfare is for you to estimate. That was not my motive."
Mr. Mowen stared dazedly about him and whispered to Paul Larkin, "Something's gone screwy here."
"Oh, shut up!" snapped Larkin.
"I am sure, Mr. Rearden," said the eldest judge, "that you do not really believe - nor does the public - that we wish to treat you as a sacrificial victim. If anyone has been laboring under such a misapprehension, we are anxious to prove that it is not true."

The judges retired to consider their verdict. They did not stay out long. They returned to an ominously silent courtroom - and announced that a fine of $5,000 was imposed on Henry Rearden, but that the sentence was suspended. Streaks of jeering laughter ran through the applause that swept the courtroom. The applause was aimed at Rearden, the laughter - at the judges.

Rearden stood motionless, not turning to the crowd, barely hearing the applause. He stood looking at the judges. There was no triumph in his face, no elation, only the still intensity of contemplating the enormity of the smallness of the enemy who was destroying the world. He felt as if, after a journey of years through a landscape of devastation, past the ruins of great factories, the wrecks of powerful engines, the bodies of invincible men, he had come upon the despoiler, expecting to find a giant - and had found a rat eager to scurry for cover at the first sound of a human step. If this is what has beaten us, he thought, the guilt is ours.

He was jolted back into the courtroom by the people pressing to surround him. He smiled in answer to their smiles, to the frantic tragic eagerness of their faces; there was a touch of sadness in his smile.
"God bless you, Mr. Rearden!" said an old woman with a ragged shawl over her head. "Can't you save us, Mr. Rearden? They're eating us alive, and it's no use fooling anybody about how it's the rich that they're after - do you know what's happening to us?"
"Listen, Mr. Rearden," said a man who looked like a factory worker, "it's the rich who're selling us down the river. Tell those wealthy bastards, who're so anxious to give everything away, that when they give away their palaces, they're giving away the skin off our backs." "I know it," said Rearden.
The guilt is ours, he thought. If we who were the movers, the providers, the benefactors of mankind, were willing to let the brand of evil be stamped upon us and silently to bear punishment for our virtues - what sort of "good" did we expect to triumph in the world? He looked at the people around him. They had cheered him today; they had cheered him by the side of the track of the John Galt Line. But tomorrow they would clamour for a new directive from Wesley Mouch and a free housing project from Orren Boyle, while Boyle's girders collapsed upon their heads. They would do it, because they would be told to forget, as a sin, that which had made them cheer Hank Rearden.

Why were they ready to renounce their highest moments as a sin? Why were they willing to betray the best within them? What made them believe that this earth was a realm of evil where despair was their natural fate? He could not name the reason, but he know that it had to be named. He felt it as a huge question mark within the courtroom, which it was now his duty to answer.

This was the real sentence imposed upon him, he thought - to discover what idea, what simple idea available to the simplest man, had made mankind accept the doctrines that led it to self-destruction.

Baby boomers have started reaching their retirement age in 2011, and with over 78 million of them as patients they will require care during their senior years.  Baby boomers are commonly known as the more self-reliant, gadget early adopters, and active individuals.  But with their high population number they are bound to put demand more from our health system.

In the current care delivery model we have today for senior citizens, nursing homes, hospital visits and assisted living are costly to both payers and patients.  And for that reason payers are looking to see what cost benefits would caring for patients at home and support their independences bring.

There are many reasons for the increase in demand for home health services and following is a short list to name a few:

Lower costs:  As patients are being treated at home, this alternate care location eliminates the costs associated with transport, and beds associated with charges inside a healthcare facility.

Telemedicine:  Baby boomers are known for being early adopters of technology and gadgets.  And with many of the capabilities of today’s electronic medical devices and smart phones, patients are able to remotely transmit data and have a care giver review it as part of their care. In addition, patients can even have access to a nurse and physician through video conferencing and be able to discuss their health issues from the comfort of their home.

Active life style:  As more baby boomers continue to enter retirement at a rate of 7,000 a day, many are continuing to stay active.  This most likely influences their decision to try to seek receiving care in the home instead of in a healthcare facility.

Technology:  In this area, we see that both patients and care providers benefiting from some of the technological advancements.  For home health service providers, mobile devices, and tablets have provided many much needed improved efficiencies.  Some of the examples are accessing records remotely, and transmitting information on the patient’s visit real time.

As we to see a shift toward keeping patients healthier and out of hospitals, it will become more critical for patients to receive care, participate in wellness programs and receive preventable care that can help ensure a healthier life.  Homecare services will play a significant role in helping patients with their health needs and keep healthcare costs down by reducing long/short term stays in nursing home and other assisted facilities.

More independent physicians are being solicited to connect to a community, local, or state HIE.  Since many of these entities have gone live in higher numbers this past year, and continue to see an increase especially due to the meaningful use stage 2 proposed ruling, physicians will continue to find themselves with several vendors and options from which to choose. Below are a few important areas of considerations for all providers taking the next steps forward in data exchange:

Connectivity with other existing community based (private HIEs) and state or national (NHIN):

One of the core components and purposes of an HIE is to provide continuous availability to medical records, enabling physicians to make better treatment decisions and deliver a higher quality of care in a more efficient manner.  When joining an HIE, providers must also consider what other entities the HIE can use to locate charts electronically.

Contracts:

When joining an HIE, a physician would be subscribing to the services that will be offered.  They will also be agreeing to local state laws around HIEs as well as specific liability and data security requirements set forth by the HIE. These contracts must be reviewed in great details, as they are very complex. The binding legal document will address privacy, security concerns, technical issues, as well as any obligations that maybe associated with early termination.

Usability of system and patient information:

There are several different methods of accessing a patient’s chart through an HIE.  One of the most commonly used and simplest method is via the HIE’s web portal which allows the physician to connect securely and perform record searches for patients.  This set up does not require any special software or interfacing to gain access to the record information.  Another access method that provides a seamless and common interface is through the use of physician’s EHR to request and process incoming patient’s summary chart.  This allows for some of the outside patient information to be combined with current physician’s patient records.  It is important to consider the connectivity model that can help create efficiencies for the organization, so both must be evaluated to ensure the right option is selected.

Value added services:

A great example of how some of the HIE are providing subscribers value added services is what a NC based HIE is doing.  CareConnect Carolinas a local HIE through Carolinas Health System is providing the following services:
·         Comprehensive medication list from SureScipts as well as many other local and national pharmacy networks.
·         Access to patient’s imaging records available through the hospital Information System
·         Access to Lab reports, Transcriptions, letter, Encounter details, Patient facesheet
·         Advanced alerting capabilities such as flags for drug seekers
·         Downloadable CCD (Continuity Care Document)
·         An EHR Lite to assist physicians with Meaningful Use
·         Referral management to digitize the information exchanged during the referral process
·         Web orders for certain labs at some of the health system facilities

There are other health systems that are also providing a PHR access feature for the patients.  This feature provides another method for the patient to be engaged and actively maintain their health record.  It also encourages up to date information even it is manually entered.

Pricing model:

Similar to many of the online subscription based services, HIEs fees are monthly.  Whether it is the physician or health system, they pay a reoccurring monthly fee for the length of the agreement. There is some setup fee associated with most and possibly additional third party charges when interfacing or integrating with an EHR.

Integration capabilities with existing system:

Not all HIEs provide integration with all EHR systems.  Ideally an HIE can provide a strong and tight integration with an EHR product and allow end users to simply use their electronic medical records application which they are already familiar with.  This will enable physicians to simply use the same application to manage patient charts as well as request medical records from an HIE.  But unfortunately, not all HIEs or EHRs allow for this integration.  So for some access to an HIE web portal that provides the ability to print/save the summary record is as far as the system will go.

With the proposed meaningful use stage 2, and 3 there is a stronger emphasis on the electronic exchange of medical records through a qualified Health Information Exchange.  And more physicians and organizations will begin to review some of the available HIEs in their community and state.

For several years now I have benefited from using a centralized to-do list integrated with my Outlook calendar.It offers a complete view of what activities and items I needed to accomplish everyday in an easy to use integrated fashion. But as I started relying more and more on mobile devices and tablets to conduct everyday business, I found out quickly that I needed to begin utilizing different apps that would allow me to easily view my tasks and calendars from any device, at any time.

Fortunately there were several mobile apps that allow me to maintain all my devices in sync with my Outlook tasks, with one of my favorites being toodledo. The toodledo app allows me to apply some of the principles of proper time management outlined in Steven Covey’s “The four discipline of execution,” and allows all of my “toys” to maintain the same list.

But one challenge that some face lies in deciding when to separate and manage multiple to-do lists. For example, for those physicians who are still practicing and also participating in leadership roles, managing their calendar requires a tremendous amount of discipline and time management skills. In a perfect world, a physician’s EHR messages should be able to easily integrate and populate with their Outlook tasks and calendar (securely and without any patient info). Unfortunately, not all systems integrate or sync with Outlook tasks, which means that many times users need to manage multiple lists or else rely on manual synchronization between different systems.

The good news is that many can still successfully and efficiently manage their time even when having to work with multiple lists. Best practice should always be to review your to-do list(s) daily and stick to deadlines, as this will ensure that you are continually monitoring progress are are aware of changing priorities.

By Sheldon Needed

The famous doctor and medical writer/professor Atul Gawande has written extensively on the huge benefits that a simple checklist affords in medicine, in industry, in life: Checklists offer protection against arrogance and forgetfulness, as well as being mindful of every last and important detail. Dr. Gawande explains how surgery, the construction of airplanes, and any other multi-stepped and multi-faceted procedure that involves multiple decisions –each simple, but dependent on each other– benefit from the use of a simple checklist.

That is: Before going ahead with x, perform or check:

1. xxx
2. xxx
3. xxx

By implementing such a simple concept in hospitals, many lives have been saved, industrial accidents have been avoided, and outcomes have improved in many areas. Checklists are “Best Practices” mandated into operating procedures that are enforced. People are often loathe to submit to something so simple as following a checklist srupulously, but it works. It goes without saying that a checklist consulted during the process of medical software selection can yield great benefits as well (it may even, in the very long run, help save lives!)

We, as people implementing complex medical software systems, have to be humble and systematic enough to learn a great deal from this idea:

Before you go whole-hog with a decision to implement a particular EMR / EHR, or before deciding on the type of EMR /PM you want: think it through, weigh the implications of decisions, in other words: make a smart checklist. Don’t be swayed by a glitzy demo. Weigh each critical point and factor it into your decision..

If you have thought these issues through for your practice, and can work up a meaningful checklist about what you need in a product, and which products offer you what you need, more power to you: But many of us are not that clear-headed, especially when we have so many other things to do, and when advertising tempts us with benefits that may or may not be available to us with certain medical software.

If you do not have this checklist in hand or in your head, CTS offers you a thorough checklist, the EMR / EHR DemoScorecard , that is easy to use and completely free of charge: it is excel-based, allows you to choose only the features you need and want to compare, and helps you rate and score vendor demonstrations as you move along in the selection process.

Some of the specific uses of the EMR / EHR DemoScorecard

• Perform a pre-demo needs medical office needs analysis to make sure you evaluate the functionality needed to manage your practice
• Customize software demos to your exact requirements
• Score each software demo based on your ratings of chosen necessary features
• Compare features and options for different packages side-by-side
• Streamline the demo process and save valuable time
• Reduce your risk of selecting the wrong EMR software by developing a fact-based analysis of each program

The areas covered in the medical software checklist include almost anything you might want to consider when making your software selection:
Areas Covered

• EMR / EHR
• Ease of Use/Learning
• Security/HIPPA
• Procedure/Diagnostic Codes
• Fee Schedules
• Insurance Companies
• Practice Management Accounting
• Work Flow
• Appointment Scheduling
• Insurance Verification
• Account/Patient Information
• Billing Claims
• Managed Care, Case Management
• Hospital Tracking
• Clinical Documentation
• Document Management Reporting
• Training  

It is easy to get the Demo Scorecard Checklist at no cost. Just sign up for the CTS Medical software selection kit, and you will be able to download the Demo Scorecard /Checklist right away.

Look at a service that compares high quality EMRs by module such as the CTS Medical Software download kit, and see what different vendors offer in the way of patient portal features.

By Sheldon Needle

When considering a Patient Portal for your EMR, don’t take an all-or-nothing attitude about the features you can manage to incorporate.

Many small to medium practices cannot get excited about the use of patient web portal modules for their still-new EMRs. They feel it will require too much input from their side (HIPAA issues, security issues, possible billing for e-visits, portability and export options to other systems) and just something else large to go wrong. Patient portals can incorporate so many functions, and they do require the attention of doctors, nurses and administrators.

But a modified – or not fully functional patient portal — offers so many advantages and efficiencies even to a smaller practice. In medical practices and EMRs it is important not to maintain an “all or nothing” attitude. Just because your practice may not be ready to go for the whole bells-and-whistles use of a patient portal does not mean that you should forego the obvious advantages that a modest patient portal – or a not yet fully utilized patient portal – can afford to your medical practice.

Here are some of these advantages:

1. Confidential email for simple queries that would take you, your receptionist, and the patient so much longer to answer than the simple query. This way, no one is obligated to get off the phone, return a call, or complete the circuit immediately. Queries can be answered at your relative leisure.
2. Easy way to transmit preventive care information. You can send patients exercise, diets, which you keep stored and organized in a database online. It saves you and your staff time.
3. Quick and more efficient way to collect revenues. Most people don’t have to think too hard to pay a bill online: easier and cheaper for the patient than to find an envelope, get your checkbook out, locate a stamp and get to the mailbox. So much less work for your office staff!
4. Requests for prescriptions are simple: even if you have not yet implemented e-prescription software, at least the request can be handled at your leisure.
5. It is definitely the direction the world is going in: Why wait till the 11th hour to implement something that will help you during hour #1?

Of course in situations where the insurer and the provider is one and the same (we are not naming names here, but we all know there are a few large examples of such companies) there is much greater incentive to create full-service patient portals. For instance, there is every reason to want to eliminate visits that are unnecessary, both for the doctors’ and patients’ sake, and for the sake of the bottom line: eliminating extra visits saves money. A small practice may not have the luxury of thinking big enough, and may be happier to have the extra appointments happen.

If you are considering a major EMR or EHR system, the system will surely offer a patient portal. If you are using, or contemplating using a smaller EMR, that does not incorporate a patient portal, there are stand-alone patient portals that can work with your EMR. These are generally simpler and have fewer functions, but nevertheless do enough of the job to be of great value to you, or much more value than no patient portal.

If you are considering a serious patient portal, here are some basic critical features to look for:

1. Integration of secure credit card and bill handling processes
2. The ability to hand off patients’ EMR data to a CCD/CCR (Continuity of Care Record / or Document). If you are buying into an EMR and its patient portal for the long term, or even the semi-long term, we are not far from the era of the ubiquitous use of a PHR (Personal Health Records) like Microsoft’s Healthvault, Epic’s Lucy, or Google Health
3. The availability of e-visits; clarification of costs for e-visits, if there will be costs. The ability for patients to update their EMR records through their Patient Portals (changes in medical condition, weight, symptoms)
4. On line prescription service to interface with an e-percription module.

Though you may choose not to integrate all the features that a patient portal offers, you need to create the beginning of a patient portal to make your patients lives’ – and your own work – easier in the long run.

Look at a service that compares high quality EMRs by module such as the CTS Medical Software download kit, and see what different vendors offer in the way of patient portal features.

By Sheldon Needed

What if this is not the first time you have chosen an EMR? If this sounds like reality TV rather than nightmare on Elm Street, console yourself by knowing you are not the first practice that has had to move from one EMR to another.

There are many reasons why, in this first serious generation of Electronic Medical Records, you might have to switch from your current EMR to a better model EMR. This is often not a matter of pique or keeping up with the Joneses, but of practice necessity.

Any of the following scenarios could require a switch:

1. You are using an uncertified EMR and you want to qualify for meaningful use standards and EHR stimulus incentives.
2. You have separate, stand alone Practice Management Software and you want to move to an integrated EMR/PM system
3. Your vendor has gone out of business, and is not upgrading or supporting his software (for instance, you cannot accommodate the new ICD-10 coding)
4. You never felt that the vendor provided decent support or training, the thing is a boondoggle, and you don’t want to throw good money after bad.

How to make this switch intelligently? There are many angles to this upgrade that need to be explored:

• First decide whether you want to move to a really different animal or stick with the same beast of burden; i.e., if you are using a client/server model, do you want to buy/lease another one, or do you want to try a web-based solution? Talk to people who are using both, talk to software reps, try to get honest technical input.
• Evaluate the big packages carefully using reputable information from a service like CTS, Inc. CTS also has software tools to help you compare features on packages. Make sure you are only considering CCHIT-certified systems that are qualified for Meaningful Use so that you can qualify for government payments and incentives as a result of using your new EMR.
• Think about financing. How do you aim to pay for this upgrade, or switch? Many vendors, like car salesman, offer financing packages. See what makes most sense for your practice: buying, or leasing, Talk to practices who have done this before. Don’t jump! Obviously, client/server models demand a bigger up front cost than web or cloud based EMR. How difficult would it be to move from one model to the other (if that is a move you are considering). Get tax and investing advice. Learn about the Section 179 Deduction and Bonus Depreciation.
• Make sure you have a list of qualities that your system must have and must accommodate before you meet vendors: Do you have multi-locations? Do you need mobile devices? Does the vendor offer different tiers of training options at affordable prices? Ask these questions of any reps trying sell you a system.
• Don’t confuse short-term expenses with serious long-term costs. Making the wrong decision by choosing an inexpensive, but low-quality system that doesn’t do what you need a system to do is much more expensive than paying for a few hours or even a few days of good advice. Hire a qualified consultant to advise you on the answers to some of these questions.

Words to the wise regarding consultants: A few hours of relatively expensive consulting time will be much less expensive than years of heartache and mountains of bills engendered by a poor move. Since your problem of data and system migration are not unique to you, many software consultants have realized that medical data migration is a very viable business these days. If you are going to hire a consultant, make sure you get solid references. Have your IT person (or IT designate in your practice) work with you to make up an exhaustive list of questions. Have respect for an occasional answer of “I don’t know how I would do that, but let me think about it and get back to you”. If he doesn’t get back to you after his honest humility has caused him to think, forget about him.

Another warning: Don’t buy or lease more system than you need, but don’t buy something this is closed and will not allow you to expand and include additional system functions. Leave room to grow in your system, and remember that technology, and government requirements, expand infinitely.

I spend a good deal of time with clients these days who are trying to connect web services, implement service oriented architecture (SOA), and moving to the cloud. All these requirements are focused on integration of multiple, sometimes legacy sometimes modern, systems but most of them still require lots of HL7 interfacing. Some of my clients start their integration efforts hoping that there is something better or more modern than HL7 but the truth is that HL7 and interfacing remains the backbone of health system integration. Choosing an integration tool is time consuming so I reached out to Craig Cunic, the Product Director of Interface Engine Team at Iatric Systems, to get some advice on how to choose an interfacing engine. Iatric has been solving complex health IT problems for a while so it’s worth following’s Craig’s advice on the Dos and Don’ts for Interface Engine Consideration. Here’s what he said:

It has been suggested that due to the advent of web services, Service-Oriented Architecture (SOA), and cloud computing, interface engines no longer serve as the proper tool for system integration. Is the interface engine dead? Yes, it is, if the interface engine does not have the necessary feature-set to support the growing number of data standards and if it can’t exchange data with today’s diverse healthcare systems and devices.

Today’s interface engine is an advanced integration engine.

The interface engine is not dead. Today’s interface engine is alive and well…and it is one with advanced features that turn it into a mighty integration engine. It is one that has extensive security and privacy features and the scalability to grow with your increased interface needs. Today’s interface engine also integrates clinical portals and medical devices, achieves other complex integration situations and supports Meaningful Use mandates. And, an advanced integration engine is easy on your IT budget: it helps control the budget because there are no ongoing interface costs.

If you are considering upgrading your current interface engine to an advanced integration engine or want to move away from point-to-point interfaces, here are the dos and don’ts to consider when researching and evaluating different integration engines:

• Do consider engines built on modern platforms such as .NET or J2EE. These will have a leg up on the competition in terms of being able to fulfill many of the requirements mentioned above.
• Don’t overlook the potential barriers in data sharing. Look for an engine that can simplify these types of communications: direct to database (ADBC, OLE, DB, Oracle and SQL), transfer types MLLP, TCP/IP, folder shares FTP (SFTP and FTPS) and SOAP.
• Don’t select any engine that is built on outdated technology. Look for engines built on advanced architectures to ensure scalability and extensibility and to support new formats and new demands as they arise.
• Do look beyond the engine’s interface capabilities – look into its ability to monitor all activity in real time and deliver exception notifications automatically. Engines using a visual IDE are best. Monitoring performance and sending problem alerts are critical for minimizing downtime, which has a negative effect on healthcare.
• Do analyze the vendor that is offering the solution and evaluate the level of customization that the vendor provides to meet your specific security needs. Also look at how much support the vendor provides in terms of minimizing IT effort at your organization.
• Do make sure the engine supports all major standard messaging data formats (delimited, fixed length, HL7 2.x and XML).
• Do consider the time that must be dedicated to set up each interface, train users, record updates and generate useful reports.
• Don’t forget that modern systems need to integrate using scripting languages such as PHP, Ruby, Perl, and Python. While .NET and J2EE are kinds of the enterprise world, scripting and glue languages are the yeoman of the integration world.

Interface engines are a core element in today’s healthcare environment, and are a requirement to achieve interoperability and meet Meaningful Use. The interface engine you choose should not only streamline your healthcare organization’s ability to share medical data with providers, patients and the community, but also minimize the IT efforts necessary to accomplish this sharing.

Like many of you, I made the annual pilgrimage to the HIMSS Conference last month but I didn’t write much publicly about it (I mostly wrote private analyst reports for specific clients). There’s so much noise at such a big conference that I like writing about HIMSS gatherings after a little time has passed and I can discuss the market landscape with vendors outside the craziness of the conference. Here’s what I learned while I was in Vegas and my takeaways for the rest of the year.

Major developments in Health IT for the rest of 2012

It was discussed a lot in the educational sessions and vendors didn’t talk about it much, but the new realities of complex business models (like PCMH and ACOs) mean that standardization of clinical workflows won’t really be possible for a while. The open secret is that most EHRs are not up to the task of handling the complexities of new business models, though. I believe the big shift to cloud computing and mHealth will mean that smaller and more nimble “apps” (both web based and mobile) will start to shoulder more of the burdens that are being thrown in by new business models. When you add more services (like smaller cloud apps and mHealth apps) more and more orchestration across services and apps is necessary (not larger apps).  The common wisdom is that there will be fewer EHRs as consolidation occurs but that’s not going to happen – interfacing, interoperability, and real service based platforms will be created that can handle the next level of more sophisticated requirements. We’ll move from basic record keeping and document management to more refined patient management, patient engagement, social electronic health records, and collaboration-driven software. The older vendors will start to hear the collaboration siren songs and jump on board pretty quickly.

How the role of EHRs will change

The best EMRs will be those that become the central “dashboard” around the most complex healthcare workflows and begin to really become “coordinators” amongst multiple systems instead of a monolithic application. Clinicians really need to understand that their EHRs need to be their patients’ social health record and relationship management system and not just their chart management system. The role of the EMR must and will change to being the patient-centric collaboration and engagement driver and will just happen to store documents, charts, and MU records as a byproduct. When retrospective documentation becomes a byproduct of more collaborative care systems then we all win.

Developments in coordinated care

I’m not sold on coordinated care technologies “writ large” – the problem is that the government and vendors are making it sound as if this is the first time care has been coordinated. In reality, care has always been (at least minimally) coordinated in the physical realm – e.g. referrals have been used to coordinate care for decades. The level of technology coordination and the amount of measurements that have always been tough to define, implement, and secure continue to remain just as difficult. The good news is that we’re all in agreement that we need to coordinate care; the bad news is that we don’t really know what that means but we’re seeing vendors say they have systems that support it (which means they’re either misleading customers or they don’t know what they’re talking about). Care coordination is about clinical integration as opposed to record sharing and we have a long way to go to really implement seamless coordination even though we have the basic technologies available to do so now (the basic technologies are social media, e-mail, and the web, not EHRs).

Security challenges need more thought and attention

The privacy rules are getting tighter and tighter but the relationships between care providers are expanding farther and deeper. For example, now all IT vendors that used to be just contractors are in some respects HIPAA business associates – there are tons of implications for vendors that they’ve not started to grasp yet. Also, think about PCMH and ACOs – they create new business relationships and care models that create significant headaches for security professionals. The healthcare world, while it’s getting more complicated, wants to get more secure at the time and it’s not reasonable to think you can make business models more complex and at the same time have more security – something’s going to give.

Don’t think HIPAA means security

At HIMSS people kept tying security and HIPAA – as I reminded my readers last year, HIPAA is not really a security standard – it’s a compliance framework and provides general guidance. I continue to recommend that organizations expand their focus from HIPAA when constructing their healthcare security policy, and model their documents off of NIST (National Institute of Standards and Technology) and other resources. NIST actually provides measures, security controls, risk frameworks, and standards that can be followed. If you follow general NIST guidelines and have really secure systems based on NIST suggestions then meeting HIPAA regulations are a piece of cake.

Biggest HIT-related and healthcare changes that physicians should prepare for

HIPAA 5010, ICD-10, and MU Phase 1/2 will keep everyone busy; start to worry about converting all your vendors into HIPAA business associates and become experts at data integration and connecting multiple software systems. Forget your focus on vertical (e.g. EHR) applications and start to focus on best of breed, smaller apps, and integrating multiple apps.

Role of payers in setting technology solution standards

The role of payers in setting technology standards is growing and will be significant and consequential – in fact, without the payers driving the train nothing will really happen. Now that Medicare has taken the lead, the big payers will be right behind. The beneficiaries of ACOs are likely to first be payers, not just patients. I’ll be writing more about this in the future.

Now that we’ve had a month to think about it, what is your follow up advice from the HIMSS’12 Conference? Drop me a note below.

I was recently interviewed for a nice article on why and how private physician practices should push for new technologies. Andrea Downing Peck did a pretty good job putting together a collage of views from me and some of my well known colleagues online: Mary Pat Whaley, David Henriksen, Dr. Jaan Sidorov, Shari Crooker, Rosemarie Nelson, David Harvey, David Williams.

Here are some of my favorite quotes (taken directly from the article):

• Mary Pat Whaley: "Patients are saying, ‘If I can’t register for your practice online or ask for an appointment or get a prescription online, I really don’t want to work with you. If the convenience isn’t there, [they] don’t have time in [their] lives for a physician who is not going to offer these things."
• About Data safety remaining a concern with cloud computing, Dr. Sidorov say: "Is all that patient information really secure being stored on some server in Singapore? Will it be easier for some hacker to [break] into that particular database? Maybe I don’t know. It’s probably better than storing patient information on a local server in a closet next to a water heater in a typical physician’s office."
• David E. Williams: "The physician’s office is one of the last places you can go into where, if you’re Rip Van Winkle and have been asleep since the 1950s, you’ll feel comfortable there seeing all the colored tab folders with the patient records and so on.”
• Shahid Shah: “As long as we have insurance, any PCP, especially those dealing with the elderly, are probably safe not being super advanced," he says. "But if you’re a practice that wants to go after the high-end, high-value profitability patient, you’re signing your death warrant if you are not [technologically] advanced.”
• Dr. Warwick Charlton suggests modular technology solutions: "If your system is monolithic…it’s very hard to get that incremental gain that dedicated modular systems can get. Over the long run, it’s a less scalable, less technologically adaptable answer."

Probably the single best advice came in the paragraph below (make sure to get the integration with advanced functionality):

Describing the practice’s first go-round with an EHR as "disastrous because it was so complicated and expensive," McMahon has made paramount selecting the right EHR/PM this time around. Her wish list for a cloud-based integrated EHR/PM system makes ease of use a priority along with features such as voice dictation, e-prescribing, integration with scanners and fax machines, interfaces with existing medical equipment, and a patient portal that offers appointment reminders and bill payment options.

When looking for integrated solutions, though, be sure to heed Dr. Charlton’s advice and go modular and not monolithic. Over the long run, no single solution will fit your bill so you need to prepared to become an integration specialist.

Ministry has been championing “real-time documentation”, that is, the practice of entering patient information into the EHR at the time it is collected. Historically, caregivers have clung to the old process of writing on paper and then re-entering it into the EHR later. Our Nurse Informaticians  are doing the hard work of changing that practice. In the areas where we have seen the change, the nurses are reporting that it has given them more time to spend with their patients. The elimination of transcription also means real-time documentation is a more accurate practice.

The following headline caught my eye as I was reading through my RSS feed:

How to deploy ERP in 120 days

As soon as I read this headline I knew I was going to unleash a rant.

Remember, the HITECH act (aka Meaningful Use) is a an incentive program, not a mandate. As we look at stage 2 we will be evaluating the increasing effort against against the decreasing financial incentive – remember stage 2 is worth less than half than stage 1.

Sure there is a supposed penalty, and we will need to take that into account too. But that penalty, starting in 2015 (or later), will be based on the amount of Medicare increase. Medicare may not be increasing by 2015.

Before I pitch a multi-million dollar effort to the senior management team we have to evaluate the ROI.

The other consideration is how much of the Stage 2 objectives are in synch with our patient care executives vision for clinical IT.

Self-care in e-space and the need to Impress

Kim MI, Johnson KB. Personal Health Records: Evaluation of Functionality and Utility. Journal of the American Medical Informatics Association. 2002. Mar-Apr; 9(2):171-180. Selected for inclusion in the IMIA 2003 Yearbook of Medical Informatics. 

Kim MI, Johnson KB. Personal Health Records: Evaluation of Functionality and Utility. Journal of the American Medical Informatics Association. 2002. Mar-Apr; 9(2):171-180. Selected for inclusion in the IMIA 2003 Yearbook of Medical Informatics. 

This week I had the unfortunate need to take my car in for service. My car is over five years old and is the family workhouse - it hauls kids, all my stuff (I never travel with less than 4 bags), project materials, the dogs...you get the picture. I cannot be without a car.

Despite the age and warranty status of my vehicle, my dealer provides me with a loaner. I used to think this was some sort of privilege I had earned once I was buying cars from a dealer, but now I realize that it is really just smart marketing.

My dealer puts me in a low mileage, nearly new, PRISTINE vehicle to drive around in for the week KNOWING it will give me the new car bug. They know our history - we have been in the same brand of car (Acura - shameless plug) for over 15 years. We have been through various models, new and used, and now are driving cars 5 to 7 years old. Prime candidates to give in to that new car smell and all the cool gadgets you can get now.

I thought about how that brilliance can be applied to my business. So many organizations are running old applications just to get to the old data. They are relying on those old workhorse machines to keep their data safe and ignoring the risks that decision is creating. Often it is because of an unfamiliarity with the potential solutions out there or that there are even solutions in existence. Once the information gap is closed, most organizations go into analysis paralysis. They get so overwhelmed with defining their archive needs that they spend months or even years shopping for a partner. And maintenance fees keep going up, hardware gets blindly replaced, and risks increase.

I say - "take a test drive". Pick one system and let us archive it for you in our solution set. See how easy it is to implement and use. Work with and get to know our world class staff and methodologies that we are continuously improving. We will even work with you on price to insure your satisfaction with your trial. Get a feel for just how easy it is to unburden your institution of costs, risk, and stress.

Now I'm off to sign the papers on that car...

The number of RFP’s for data archiving projects has increased greatly over the past year. Personally, I don’t think it’s the need that is growing (I think it was always there!); I just think more institutions are finally treating solutions such as ours with the formality they deserve. Archiving requirements vary greatly within and across departments depending on the type of data, the type of system, the age of the data, and what the data is being used for, not to mention the institution’s strategic initiatives around electronic medical record and data retention.

When a large facility is seeking a data archiving partner, there are things that need to be considered:

• RFP requirements need to be considered from the overall solution level in terms of technical integration with existing web services, hardware requirements, SLA’s, project and customer management.

• The primary systems, the main stakeholder department (HIM, PFS, etc.) and their target retirement date needs to be identified and provided as part of the RFP. Include the vendor and any technical information that can be provided.

• Take the time to at least identify at a high level, the functional requirements for each main system being retired. Try to put yourself forward in time to imagine what functions and interfaces you will still be running or that you will require at the date that system retires.

• Consider and include any reporting needs you have, and specifically identify if you will need them running automatically on a schedule or on demand.

• Think about your in-house support model going forward; will you centralize archived systems under one area in IT? How will you manage these from a help desk perspective? Contracting and legal perspective?

• How will you integrate this strategy into your PMO and your new projects? The sooner you have a strategy that can be systematically plugged into current and future project plans and budgets, the sooner you will realize the savings in time and money that an archiving partner provides.

• Check references, hopefully from areas and with applications similar to your stakeholders. Make sure HIM resources talk to HIM resources at the vendor’s reference sites.

Make sure you ask for “like” responses from all vendors. Some questions that will assist with this include:

“Please provide any PER USER or PER LICENSE pricing that your solution requires.”

“For each functional requirement, indicate if the implementation of that requirement is included in the prices quoted or if additional fees would be incurred.”

“For each functional requirement, indicate if a modification is required or if your base solution contains this functionality. If a modification is required, please estimate the additional cost”.

“Please indicate any PER INTERFACE or PER REPORT pricing that your solution requires”.

“Please indicate if your system has standard screens or if screens are customizable. For customizations, please indicate the additional charge and/or support implications.”

“Please cost out a typical Revenue Cycle archiving system cost that includes the following:

1. NN custom reports that will run daily, weekly, monthly

2. N Agency interfaces that include demographics outbound and transactions inbound (posting)

3. UB/837 outbound interface, running daily

4. 100 users.”

Finally, make sure that you allocate enough time for the on-site demos and that all stakeholders are present. Break them up by functional area if necessary to allow all decision makers a chance to thoroughly see the vendor’s solution. Provide a script if possible that the vendors should follow so that the demos are easy to compare each step of the way.

Managing an RFP for an archiving partner can be a complex and difficult task, but the time spent diligently on the selection process will pay off in the long run and provide you with a partner that you can have extreme confidence in far into the future.

I have been doing a lot of reading lately on Accountable Care Organizations, or ACO's.  Yet another acronym in healthcare, as if we needed any more! As a consumer of healthcare, I get it.  No one has any problem paying for good service when it is received.  We take our car to get repaired, and we expect it to be fixed when it is returned.  Prior to taking it, however, we do shop around.  Some of us are looking for the highest quality work at the best price.  Others of us might have to sacrifice quality or make adjustments to our expectations based on what we are able to spend.  ACO's, if implemented correctly, would certainly provide consumers with the information to make such informed decisions when it comes to their healthcare and would compensate providers based on quality outcomes.

There are just a few problems with this model, however.  First of all, human beings are not cars.  While the average person understands that if they cannot afford to get their car fixed, they must make sacrifices or find alternate transportation, those same people tend to feel they have a right to the highest level and quality of healthcare regardless of their ability to pay.  I don't want to get into any sort of debate here about socialized medicine or a person's right to health care, my point is just that people have a different mindset about the quality of their healthcare vs other consumer services.

The other problem with the model also goes back to the fact that human beings are not cars. Healthcare is an art, not a science, so while we are very progressed as far as identifying and curing illnesses, the fact remains that outcomes are not 100% predictable no matter how high the quality of the services performed.

So what, pray tell, does this mean to me, or for that matter FOR me, in terms of my business? It means that the powers-that-be have a lot of work to do to put together a sustainable model for ACO's, and that the main component of that work is going to be (insert sound of trumpets here)…DATA. There is not going to be one simple formula to determine a quality outcome, and there is not going to be one simple dataset that will go into the calculation.  Besides the obvious data that is collected during a episode of care, the data will need to include family history, personal health history, habits, environment, even social and cultural factors, as all of these items can influence a person's health and response to treatment.

It really means that now, more than ever, all types of providers MUST preserve ALL data that they collect, no matter their longterm EHR strategy, no matter their conversion strategy, or what data elements the "experts" have determined are important.  EVEN IF you convert data to a new application, you run the risk of missing that crucial piece of information, that small nuance, that could be impacting outcomes.  Are you willing to take that chance??

Healthcare is transforming like never before, and in all aspects,  from the business structure to the reimbursement structure to how care is monitored and managed. Now, more than ever, the data that you collect across that continuum of delivery must be preserved in its original format, definition and detail.  It is essential that providers have a cost effective, risk mitigating solution that allows this level of data preservation.

There are 5615 journals currently indexed in PubMed. I was curious to know which of these journals is publishing articles on eHealth. I searched the Medical Subject Headings (MeSH) using the word: “eHealth” and found three entry terms: eHealth, Mobile Health and Telehealth. I adapted a script and ran individual searches on the years 2010, 2011 and another search that included records from 1977 to the present. This resulted in 4908 articles. The findings are graphed in Figure 1.

Figure 1: Journals indexed in PubMed using MeSH term “eHealth”

(If you wish to know the full name of the journal you can look it up in the National Library of Medicine LocatorPlus).

A wide variety of journals contained articles that were indexed using these terms, including some of which are written in languages other than English (Sov zdravoohr  is in Russian and Lakartidningen is in Swedish). One note of interest is the change in the abbreviation for the British Medical Journal from Br Med J to BMJ, which resulted in it being listed twice. I was somewhat shocked that neither Informatics for Health and Social Care (formerly known as Medical Informatics and the Internet in Medicine) nor BMC Medical Informatics and Decision Making appears on the list given that their content includes publications in eHealth. It may be that these articles are indexed only with the term “informatics”, which is listed in MeSH.

I conducted the search again using the MeSH terms for “Social Media” (Social Media, Social Medium and Web 2.0). This resulted in 721 hits, which is not surprising given that these terms are relatively new in comparison to those associated with eHealth. Figure 2 illustrates the findings.

Figure 2: Journals indexed in PubMed using MeSH term “Social Media”

When you submit an article for publication to a journal you are often asked to supply keywords that describe the content of your paper. In some cases you are explicitly asked to use MeSH terms. In cases where an article does not have MeSH terms they are indexed by staff at PubMed. In either case there may be publications that include material on eHealth or social media that are not being labeled as such.

There are six journals (Journal of Medical Internet Research, Studies in Health Technology and Informatics, Conference proceedings: Annual International Conference of the IEEE Engineering in Medicine and Biology Society, AMIA Annual Symposium Proceedings, Caring and the British Medical Journal) that are found on both lists. Either the authors of these articles, the journals that publish these papers or PubMed are ensuring these terms are being used.

Those who conduct searches of PubMed using these MeSH terms may be missing important publications in these fields. It is likely the author(s) of the papers who understand its content with the precision required to ensure proper indexing. We all want our publications to reach the right audience. Therefore as authors need to be aware of the MeSH terms, how they are used and be more consistent in indexing our papers.

Introduction

Many of us are familiar with Charles Minard’s map of Napoleon’s March to Moscow in 1812 (Figure 1). This map has been reproduced in various publications including Edward Tufte’s “The Visual Display of Quantitative Information”. As Tufte noted the map provides us with various pieces of data: the width of the brown line indicates the size of the army as it travels east and the black line as it retreats in a westerly direction. The dates and temperature that correspond with progress of the march are included. Also provided are the longitude and latitude, which situate the location within the larger geographical context. This map, concise in format and useful in providing various forms of data, has been referred to as the “best visualization ever made”.  I believe this conclusion should be reconsidered.

Figure 1: Napoleon’s March to Moscow

With recent technological advances such as Google Map and application programming interfaces (API) we now have access to web-based tools that allow this map to be re-created in an interactive format. Figure 2 shows this map in a “Hybrid” view, which combines the Map and Terrain options.

Figure 2: Flow Map of Napoleon’s March to Moscow

Source: http://hci.stanford.edu/jheer/files/zoo/ex/maps/napoleon.html

The tools (located in the upper left corner of Figure 2) can be used to zoom in on specific areas of the map for greater detail or zoom out to situate it relative to other parts of Europe. However, even with this rendition we still do not know the complete story of what transpired on the march. For example, no explanation is available for why the army diminished in size. We can postulate they engaged in battle, fell victim to disease, adverse weather conditions or perhaps starvation. History texts or other sources such as narratives by the soldiers would provide clarity. The map (Figure 1) was created by Minard fifty seven years after the march took place. How might Napoleon have altered his strategy if simple details such as terrain or weather had been provided?

Conveying meaning through images

Below is an artists’ impression of troops traveling during the March to Moscow. What other kinds of information we can infer from this depiction? For example, we may sense that the troops are under dressed for the cold weather. Their hunched over appearance may imply that they are overwhelmed with the weight of the packs or avoiding freezing winds that are hitting their faces. Without any clear indication that they are carrying weapons beyond sticks or pitchforks they do not appear to be well prepared for battle. But perhaps the most telling element conveyed in this pictorial is emotion. It looks like they are suffering.

Image I: The men of Napoleon’s March to Moscow

Source: http://www.rideandseek.com/expedition/napoleon/overview

Communication through narrative

The following quote is taken from the same web site as Image I. The weather has changed and the soldiers are now experiencing a much warmer climate.

 By this stage of Napoleon’s invasion it was the middle of July and it was the heat rather than the cold that was becoming a major obstacle.  One veteran described the hot conditions as, “worse than anything we’d known in Egypt”. Men died of heatstroke and dysentery at such a rate that the army had been reduced in size by a third when it reached Vitebsk. The remaining men were at the end of their endurance and they hadn’t even fought a single battle! Many of them had been on the march for three months, all the way from Paris with only two days’ rest. Others had endured a forced march for 32 hours covering a daunting 170km!

Source: http://www.rideandseek.com/expedition/napoleon/overview

What other types of information can we obtain from this narrative? We now know it is possible that the troops were suffering from illness, some of them died not from combat but from disease and that the heat is also causing fatalities.

Conclusion

Many of us who work as social scientists were trained within one discipline. If it was psychology chances are you were schooled in quantitative research. Sociologists are more likely to have taken coursework in qualitative research. There are exceptions but expertise generally comes with a price. You often have to “pick a camp” and use the method associated with your field. There have been great advances in mixed methods, which is a relatively new field that combines the strengths of both of these methods. A few text books have been written on this concept. However, few universities offer mixed methods as a course because those in a position to teach have not been trained in both methods. There have also been efforts to create training programs that promote interdisciplinary collaboration. However, it is not known what happens to graduates of these programs when they return to their “home base”. How many carry on the effort of collecting both quantitative and qualitative data? We desperately need both and to find ways to incorporate them in a meaningful way.

In a previous post I used Google Charts to explore how data from a web-based source (Statistics Canada) can be mined and displayed in format that provided us with some insights. The data visualization (in the form of bar charts) demonstrated that rates of diabetes are increasing and more so in certain geographical areas of Canada. To help reduce these rates we need to further elucidate causative factors if and where possible.

Some individuals become diabetic because they are unaware they are at risk. Many not be consciously aware of why they do not engage in behaviour change(s) despite known risks. Or they do not know that by changing their diet or exercising this risk can be reduced. In some circumstances individuals may be unable to engage in lifestyle changes. For example, in some geographically remote locations access to fresh fruits and vegetables may be limited, particularly in the off season. In suburban settings there may be more reliance on using transportation rather than walking. From a visualization perspective the nature and extent in which these issues play a causative role could be explored by overlaying data sets of these variables within a GIS (geographic information system) application. Unfortunately data of this nature are currently not available in Canada. In addition, messaging can be inconsistent. We also lack detailed knowledge in our understanding of the ways in which family physicians and various media are used to inform the public of diabetes risk factors. Is the messaging consistent and effective? How can we move forward on prevention issues without understanding all the variables involved in relation to increasing diabetic rates?

In a recent study my colleagues and I explored the ways in which people with diabetes used the Internet, in particular a web-based message forum to tag or label posts as well as search for credible content using this tagging format. The study involved usability testing, interviews as well as surveys. There may be some clues in examining the dialogue that stemmed from these interviews.

In the coding of the interviews one concept predominantly mentioned was the notion of anecdotal or experiential information. In this context an anecdotal source means information that is learned informally from others with diabetes. One common phrase to describe this concept is “tricks of the trade”.  Although I did not have the type of data I had first thought about (and outlined above) I had some qualitative findings about the ways in which people with diabetes view one aspect, anecdotal information, in relation to living with this disease.  But I was also curious about the rhetoric around how providers discuss the treatment of diabetes. Since health providers were not part of this study I decided to examine the, “Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada”.  I also wanted to use information visualization techniques to explore this material. I formalized my research objective for this investigation as, “In what ways do patients and providers dialogue about the care and management of diabetes”?

In the follow sections I will provide details about the method, findings, discussion, limitations and some final thoughts.

Method

This purpose of this study was intended to explore, not explain two sources of information (one obtained in a research study with patient participants and another using written guidelines intended for health professionals to treat patients with diabetes) using a visualization technique. One tool that readily provides a visual representation of written content is a word cloud, which can be created using a web-based tool at Wordle.

The written content from the patients living with diabetes was obtained by using quotes from an interview study that had been coded as “anecdotal”. It was copied and pasted into the word cloud utility at Wordle. The written material from the provider perspective was obtained by using the “Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada”. The specific sections that were used included the material on “Insulin Therapy in Type 1 Diabetes” and “Pharmacologic Management of Type 2 Diabetes”. This material was also copied and pasted into the Wordle word cloud application. Both samples were rendered using the same font (“Lucida Sans”), colour scheme (“Ghostly”) and layout (“mostly horizontal”) format to facilitate comparison.

Findings

According to the word count feature at Wordle the three most frequent words or phrases from the patient participant anecdotal quotes (Image I) were “people” (eight times), “know” and “like”, which appeared seven times.  The words “the”, “I”, “to”, “and”, “that”, “of”, “in” and “what” were excluded.  No medical terms were mentioned (this could be because the topic matter for these quotes was anecdotal information). The word “individual” and “diabetic” were each used once.

Image I: Word cloud from patient participant anecdotal quotes

In the provider guidelines as shown in Image II (with the words “should”, “be”, “to”, “with” and “of” were removed) the top three  words were “insulin”, “antihyperglycemic” and “agents”, which were used three as were “regiments” and “lifestyle”.  The most common phrases from the patient participant anecdotal quotes (“people”, “know” and “like”) were not represented in the sections of the guidelines used to render that word cloud Image II).

 Image II: Word cloud from Canadian Diabetic Association Guidelines

Discussion

Not surprisingly patients and providers were seemingly focused on different issues. Or it could be that they used different language to articulate these issues. My first thought in seeing the frequency of the word “people” in the patient participant anecdotal quotes was to compare it to “individuals” in the provider guideline sample, which was very small in the latter cloud. Is it possible that in this context that the patients mean “community” as a group of people with diabetes in this context and the providers are referring to who they treat?

Limitations

The quotes used to create the word cloud represented material specifically about anecdotal information. This section was chosen because it was the most frequently identified content in the qualitative interviews. In addition the participants in the study were not representative of people with diabetes across Canada. The goal of the study was not related to diabetes prevention. However, as with the nature of the open format of qualitative interviews many participants shared information beyond initial intent of the inquiry.

Final Thoughts

Wordle is a tool that helped me visual something I probably would not have noticed otherwise. Although it does not offer an explanation (the context of these terms needs to be explored) it did allow me to explore the content in a new way. It is a very simplistic means of interpretation (word count) but I’m excited about the possibilities that this and other types of information visualization can bring to aid exploring qualitative research.  On one level this very (very!) exploratory examination could be an indication of a very deeper problem: the issues that providers value and consider important to include in treatment guidelines may be quite different from those in which patients’ value. How do we get patients and providers on the same page?  Social media may be one way of closing the gap. Electronic health records that provide a space for patients and providers to dialogue may be another means. Either way each side needs to be aware of the differences and acknowledge that moving towards a shared repertoire through mutual engagement to negotiate new meaning is imperative to help reduce increasing rates of diabetes.

WHAT IS ACUPUNCTURE?
Acupuncture involves stimulating points on the body, using thin, solid, metallic needles that are manipulated by hand or by electrical stimulation. Chinese tradition teaches acupuncture practitioners that the aim is to improve levels of qi, which is considered the energy force behind all life, and restore balance in the opposing forces of yin and yang. The needles are placed along meridians, invisible energy channels described in ancient Chinese manuscripts as running the length of the body.

Building an Evidence Base: Clinical Research Progress
“Our goal is to build a house of evidence,” explains long-time NCCAM grantee Brian Berman, M.D., director of the Center for Integrative Medicine at the University of Maryland School of Medicine.
To date, much of the progress in clinical research on acupuncture has come from an interdisciplinary approach that includes experts in acupuncture, clinical trial methodology, biostatistics, and relevant diseases such as osteoarthritis or carpal tunnel syndrome.
“What we’ve learned so far is that the most promising area for using acupuncture is pain,” says Dr. Nahin. Clinical studies are showing acupuncture’s efficacy for some types of pain, such as back, osteoarthritis, and postoperative pain. For example, a systematic review supports the use of acupuncture for postoperative pain management. An NCCAM-supported Phase III clinical trial led by Dr. Berman showed that acupuncture relieved pain and improved function in patients with knee osteoarthritis when it was used with standard medical care, including anti-inflammatory medications and opioid pain relievers. In a large study published in 2009, researchers found that people suffering from chronic low-back pain who received acupuncture or simulated acupuncture treatments fared better than those receiving only conventional care. Pilot studies have looked at acupuncture in posttraumatic stress disorder and chemotherapy-induced nausea and vomiting. And, the Cochrane Collaboration reviewed 11 randomized trials and found that acupuncture may be a valuable option for patients suffering from tension headaches.
But these clinical outcomes may involve more than acupoints and needles. Other aspects of the acupuncture experience may play important roles in healing, including reassurance provided by the practitioner, expectation of benefit, and the sensory experience elicited by acupuncture needling, which has been called de qi and variously described as aching, dull pain, tingling, or a heaviness. In several recent studies researchers have carefully designed their studies to compare true acupuncture to simulated acupuncture and have tried to mimic the sensory experience of true acupuncture so that patients would be unaware of whether they were receiving true or simulated acupuncture. In some of these studies, such as the 2009 study on low-back pain, both simulated acupuncture and real acupuncture produced greater benefit than standard therapy.

Source:

Sources:
NationalNCCAM, National Institutes of Health
Bethesda, Maryland 20892 USA

Many people take dietary supplements in an effort to be well and stay healthy. With so many dietary supplements available and so many claims made about their health benefits, how can a consumer decide what’s safe and effective? This fact sheet provides a general overview of dietary supplements, discusses safety considerations, and suggests sources for additional information.

Key Points

• Federal regulations for dietary supplements are very different from those for prescription and over-the-counter drugs. For example, a dietary supplement manufacturer does not have to prove a product’s safety and effectiveness before it is marketed.
• If you are thinking about using a dietary supplement, first get information on it from reliable sources. Keep in mind that dietary supplements may interact with medications or other dietary supplements and may contain ingredients not listed on the label.
• Tell your health care providers about any complementary and alternative practices you use, including dietary supplements. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

About Dietary Supplements

© Jupiterimages

Dietary supplements were defined in a law passed by Congress in 1994 called the Dietary Supplement Health and Education Act (DSHEA). According to DSHEA, a dietary supplement is a product that:

• Is intended to supplement the diet
• Contains one or more dietary ingredients (including vitamins, minerals, herbs or other botanicals, amino acids, and certain other substances) or their constituents
• Is intended to be taken by mouth, in forms such as tablet, capsule, powder, softgel, gelcap, or liquid
• Is labeled as being a dietary supplement.

Herbal supplements are one type of dietary supplement. An herb is a plant or plant part (such as leaves, flowers, or seeds) that is used for its flavor, scent, and/or therapeutic properties. “Botanical” is often used as a synonym for “herb.” An herbal supplement may contain a single herb or mixtures of herbs.

Research has shown that some uses of dietary supplements are effective in preventing or treating diseases. For example, scientists have found that folic acid (a vitamin) prevents certain birth defects, and a regimen of vitamins and zinc can slow the progression of the age- related eye disease macular degeneration. Also, calcium and vitamin D supplements can be helpful in preventing and treating bone loss and osteoporosis (thinning of bone tissue).

Research has also produced some promising results suggesting that other dietary supplements may be helpful for other health conditions (e.g., omega-3 fatty acids for coronary disease), but in most cases, additional research is needed before firm conclusions can be drawn.

Source:

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In the past decade,newspaper was ubiquitious to news.We relied on Newspaper everyday to deliver us uptodate news about what was happening not only in the region in which we habitated but also for news from across the world.

The views and opinions expressed in this blog are mine personally and are not necessarily representative of current or former employers.

The Good Boss

One of my assignments as a young captain was serving as the convoy commander for our combat engineer battalion. We were moving over 250 vehicles across the state of Colorado. Given the size and type of vehicles (Hummers, dump trucks, semi-tractors carrying bulldozers), we covered a good 15 miles of highway end to end.

I missed a turn and inadvertently split my convoy in two. Applying a few off-road techniques, I’d put the pieces back together within a couple of hours. But not before catching the attention of the battalion commander.

At our next stop, I steeled myself for one of the famous ass-chewings our commander was known for. We both stepped out of our Hummers. He looked at me and said, “Carry on, Marx!” He spun back around and climbed into his vehicle.

That was it. And you know what? For me, that’s all it took and he knew it. He purposefully chose a different form of discipline for that situation. Later, he told me that he could tell by the look on my face that I had learned the lesson and understood the gravity. He did not have to say anything more. And he didn’t.

Earlier this year, I posted the Bad Boss. It is always easier to point out the negative over the positive. So what is the Good Boss?

I don’t believe there is a magical checklist of Good Boss attributes. There are too many variables and permutations. Put simply, the Good Boss first and foremost does not follow a checklist. She understands every person is unique and should be treated as such. Just like my commander following my convoy fiasco.

I crowdsourced for input. Here is a compilation of attributes of a Good Boss. This is not research or academia or consultant or stats based on one person’s experience. It is not a checklist. These are ideas, and I imagine they reflect the thinking of your staff as well. Ponder the following and adopt as your situation dictates.

Ensures Appreciation and Value

• Thanks subordinates regularly
• Demonstrates gratitude in words and action
• Rewards success
• Personalizes awards and recognition
• Listens often
• Gives the subordinate glory for success

Mentoring

• Takes active interest in the subordinate’s career and guides growth in the job
• Teaches the subordinate how to best interact with customers
• Encourages professional development and provides educational opportunities
• Willing to learn from the subordinate
• Hopes one day the subordinate will step into his position
• Guides the subordinate to their ultimate goal, even if it means losing them

Fairness

• Never steals ideas from subordinates
• Always honest and ethical to the core
• Does not undermine anyone
• Possesses a strong work ethic
• Treats everyone without bias (race, religion, ethnicity, gender, age)

Performance

• Sets high but reasonable standards and removes non-performers
• Gets more out of subordinates than they can get from themselves
• Sustains the continuity of the organization by hiring only “A” players
• Provides insightful and regular feedback
• Elevates performance without the subordinate even noticing
• Provides appropriate tools and training for the job

Team

• Holds individuals accountable to performance standards so the team does not suffer
• Represents team and department with passion and confidence
• Makes the subordinate feel proud to be on the team
• Takes public responsibility for the action of the team when failures occur

Transparency

• Makes themselves transparent and vulnerable
• Admits errors and apologizes without excuse
• Gets to know subordinate as a person (family, hobbies)
• Is in tune with their emotions and not afraid to show it (smile, laugh, cry)
• Shares their wisdom in decision making and is open to other possibilities

Vision

• Encourages vision
• Articulates and lives the mission and values of the organization
• Tells the subordinate when to be practical and when to dream

Positive

• Remains positive when things don’t go as planned
• Always finds the good in bad situations

Individuality

• Does not micromanage and allows for creativity and self-expression
• Welcomes and supports innovation and creativity
• Recognizes individuals strengths and positions people accordingly
• Knows when to be the boss, friend, or mentor
• Knows when to lighten difficult moments

Style

• Leads by influence and not by position
• Jumps In the trenches as needed
• Walks the talk and shows flexibility
• Trusts, respects, and gives benefit of the doubt
• Possesses high emotional and social intelligence

Miscellaneous

• Promotes work-life balance
• Allows for downtime
• Able to charm Joint Commission surveyors!

Is this how your employees describe you? Which of these attributes will strengthen your leadership? Remember, one size does not fit all. Treat everyone in the style that works best for that individual and circumstance.

Be the boss! The good boss.

Ed Marx is a CIO currently working for a large integrated health system. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this post. You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook and you can follow him via Twitter — user name marxists.

Quality Systems, Inc. announced this morning that it has acquired The Poseidon Group, an Atlanta-based emergency department information systems vendor. Quality Systems will integrate the Navigator PC and NavigatorWeb EDIS modules into its NextGen Inpatient Solutions small hospital product line.

NextGen Healthcare Inpatient Solutions EVP Steve Puckett was quoted as saying, “This acquisition provides our clients additional value by extending our hospital suite portfolio of advanced solutions to the Emergency Department. This product along with our surgical services suite will help support our rapid growth upward into the community hospital market.”

The acquisition closed May 1. Terms were not disclosed.

Top News

Accretive Health sends a detailed response to Senator Al Franken, who is investigating the company’s hospital collection practices. The company says its primary purpose is to help patients by making sure they use the benefits to which they are entitled, also adding that the company follows HFMA guidelines, including making it clear that services won’t be withheld for financial reasons. Accretive says it complies with all federal laws, including HIPAA, and that all but one of its missing laptops was encrypted and that one was because a now-fired employee messed up. The company also hires a boatload of influential guns-for-hire former politicians to polish its tarnished reputation: former HHS Secretaries Mike Leavitt and Donna Shalala, former Senate majority leaders Tom Daschle and Bill Frist, and former CMS administrator Mark McClellan. Newt Gingrich on Line 1?

Reader Comments

From MT Hammer: “Re: Transcend Services (now Nuance). Medical transcriptionists file a class action lawsuit against the company for labor law violations.” The 13 named transcriptionists claim that Transcend violated federal labor laws by paying them per line of text transcribed or edited but not for related activities such as looking up information, thereby dropping their compensation below the $7.25 federal minimum wage. I’m surprised that Transcend hired them as work-from-home employees instead of independent contractors, but maybe the company provides more direction than would be expected for a contractor.

From David Stock-Man: “Re: Quality Systems/NextGen. Anyone have thoughts on the company missing its numbers and shares getting crushed?” QSII announced preliminary Q4 results last Thursday, with expected revenue for the quarter of $107-111 million and EPS $0.24-0.27, blaming revenue recognition delays for missing expectations and issuing guidance down for the fiscal year. FY2013 guidance calls for revenue and earnings growth of up to 25%. Some folks on the stock message boards are crying foul, saying that pro traders were taking huge put positions in the shares right before the announcement, suggesting the possibility that word leaked out (without having any proof, of course.) Shares that were trading in the $45 range just a handful of weeks ago are down to $30. Above is a one-year graph of QSII (blue) and the Nasdaq (red). Shares have a long track record of steady growth, are now priced relatively cheaply, and the company’s margins are good, so if you’re feeling confident that this is just a bump in the road, you get to buy shares at a discount (and if you’re wrong, you get to lose even more money). All I know is that quite a few of the old-school EMR vendors seem to be failing to meet lofty expectations lately despite billions of taxpayer dollars being spent to help them sell product, so if not now, when?

HIStalk Announcements and Requests

Thanks very much to the 68 readers who donated to support the four young daughters of Epic analyst and long-time HIStalk reader Tim Dodson of Children’s Medical Center (TX), who passed away recently at 34. Including the three of us who matched $250 in contributions dollar for dollar, our total contribution was $5,495, which I’ve deposited to the fund set up by Tim’s wife Wendy for the girls, flagging it with a note saying it came from Tim’s fellow HIStalk readers. I covered the credit card fees, so every dollar you donated went directly to support the children. Those of us who chipped in know that it could have been us who died young and unexpectedly, leaving a family deprived of not only their loved one, but of their primary breadwinner as well. You did good.

Acquisitions, Funding, Business, and Stock

The Trizetto Group announces that its subsidiary Gateway EDI has acquired NHXS, a provider of contract compliance and point-of-service adjudication workflow automation. Gateway will incorporate NHXS’s capabilities into its EDI and RCM offerings.

Wolters Kluwer sells its prescription data business to PE firm Symphony Technology Group.

Simplee, which offers free online medical expense management tools for consumers, raises $6 million in a Series A funding round.

Sales

Unity Health System (NY) selects Phytel’s Atmosphere platform as part of its infrastructure for population health management.

Cape Cod Healthcare (MA) chooses Courion Suite for user access management for its Siemens Soarian system, scheduled for a December go-live.

Stewart Webster Hospital (GA), a 25-bed critical access hospital, selects the ONE EHR from RazorInsights.

The State of Arizona contracts with Mosaica Partners for consulting help in updating strategic and operations plans for the state’s HIE.

Orange Coast Memorial Medical Center (CA) selects PerfectServe’s clinical communication platform.

Hartford Hospital (CT) will deploy OTTR’s transplant system, including the recently announced OTTRvad module for ventricular assist device patients.

Norton Sound Health Corporation (AK) will deploy ambulatory and inpatient solutions from NextGen.

Chesapeake Regional Medical Center (VA) contracts with ICA Informatics to develop an HIE for its integrated delivery network.

Boston Medical Center (MA) signs a five-year license agreement with Streamline Health for use of its business intelligence and analytics solutions in 19 physician group practices, while Bronx-Lebanon Hospital Center (NY) extends its licensing agreement with Streamline Health for five years.

North Texas Accountable Healthcare Partnership (TX) selects Orion Health’s HIE solution to connect its 12,000 physicians.

Advocate Health Care (IL) selects Merge Healthcare’s cardiac imaging and informatics solution. Merge also announces that 12 radiology and orthopaedic practices have selected its EHR products.

Aetna selects Kony Solutions’ KonyOne Platform for its mobile health app.

People

The Massachusetts eHealth Institute names Laurance Stuntz (NaviNet, CSC Healthcare) as director.

e-MDs hires former CO-REC director Robyn Leone as director of public policy and government initiatives.

M*Modal brings on Kathryn Twiddy (Quintiles, Misys) as chief legal officer.

Blair Butterfield (GE Healthcare IT) joins VitalHealth Software as president of its North American division.

Announcements and Implementations

Rockford Memorial Hospital (IL) goes live next spring on the health system’s $40 million Epic system. Rockford’s physician group has been live since last year.

SoutheastHEALTH and Missouri Delta Medical Center join forces to build and manage a $3.5 million networking and data storage center for their organizations and other medical providers. Both hospitals will also install a $12 million Siemens Soarian system over the next year.

Austin Diagnostic Clinic (TX) goes lives on PatientKeeper Charge Capture for its 120 physicians.

Aetna Pharmacy Management offers its members new services based on their prescription claims data: (a) switching to once-per-day meds when appropriate; (b) recommending trying a less expensive single component of a combination drug; (c) flagging prescription that have been taken longer than recommended; (d) sending prescribers a letter for daily doses that exceed that listed in product labeling; and (e) identifying cases where a new prescription may indicate that a previous one caused side effects.

Medical billing and financial management vendor Fi-Med Management says it will expand its services and add 145 new jobs in the Milwaukee area. It says its new software can help hospitals identify over- and under-charging and avoid audits.

Other

Allscripts will train and hire 40 City College of Chicago graduates, whose salaries will be paid by the City of Chicago for their first six months.

Cerner customer The Hospital de Denia achieves HIMSS Analytics Europe Stage 7, the first Spanish hospital and the second in Europe to do so.

A Northwestern Memorial Hospital (IL) employee is charged with identity theft after a police search of her home, triggered by her use of several credit cards to pay her water bill, uncovers the credit card numbers, birth dates, and Social Security numbers of more than 50 patients.

Last weekend I had the chance to snuggle with a relative’s new baby, which reminded me of this recent article. Laptop magazine compiled a list of 15 current technologies that newborns will never see, including wired home Internet, Windowed operating systems, hard drives, the mouse, desktop computers, and fax machines. If I had written the article, I would have put an asterisk by a few of them (desktops, fax machines) and added, “Not applicable to healthcare because providers are resistant to change.”

Sponsor Updates

• Surgical Information Systems recognizes five hospital systems with 2012 SIS Perioperative Leadership Awards, among them Holy Spirit Hospital (PA – above.)
• Certify Data Systems ranks as a tier one enterprise HIE vendor in the Chilmark 2012 HIE Market Report.
• CynergisTek expands its portfolio of offerings to include the HIPAA Surveyor Solution Series and the HIPAA Audit Readiness Solution Portfolio.
• AHA Solutions and GetWellNetwork host a Webinar featuring Texas Children’s Hospital and its interactive patient care RFP process.
• PatientKeeper awards Ashe Memorial Hospital (NC) its customer innovation award.
• EHRConsultant’s AIMSConsultant division provides advice on choosing the right anesthesia information management system.
• Informatica releases its Informatica 9.5 platform, designed to maximize customers’ return on big data.
• BridgeHead Software will sponsor The Big Event social gathering at the 2012 MUSE International Conference May 29-June 1.
• Computerworld honors Lehigh Valley Network (PA) with its 2012 Laureate award and NASCAR Teamwork award for its innovative use of DigitalShare, T-System’s ED patient documentation system that’s based on Shareable Ink technology.
• Barrington Orthopedic Specialists (IL) selects NextGen’s EHR, PM, portal, and other solutions for its 15-physician practice.
• College Park Family Care Center (KS) selects eClinicalWorks EHR for its 91 providers.
• Emerson Hospital (MA) integrates Access Intelligent Forms Suite with its Meditech Magic system.
• Kareo upgrades its billing system clients to a new release, which includes enhanced claim scrubbing capabilities.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

More news: HIStalk Practice, HIStalk Mobile.

NHIN Direct, under the leadership of Dr. Doug Fridsma at the Office of the National Coordinator for Healthcare IT, is now known as The Direct Project.  According to Government Healthcare IT News, “The Direct Project is a streamlined version of the more robust nationwide health information network standards set (NHIN), and will offer physicians and small practices the ability to conduct basic health record exchanges. For example, a primary care physician who is referring a patient to a specialist can use the Direct Project to send a clinical summary of that patient to the specialist, and to receive a summary of the consultation”  Open software is available in both .Net and Java versions. Per http://directproject.org, the Direct Project specifies a simple, secure, scalable, standards-based way for participants to send encrypted health information directly to known, trusted recipients over the Internet.  It relies on the sender pushing information to a recipient, using standard e-mail protocols, and does not rely on a central registry of patients, such as would be found in the NHIN Connect solution.

See also:  http://www.govhealthit.com/newsitem.aspx?nid=75326

http://wordpress.org/news/2010/09/ios-v2-6/

EHR Meaningful Use Press Conference from HHS

So, I am watching this big football match between Barcelona and Chelsea. Me, 100.000 people at the stadium, and millions at their homes across the World. No football fan would ever want to miss this semi final UEFA Champions League game, which is just a special treat.

Anyway, during the first half an incident happens in the Barcelona’s penalty area. Didier Drogba, Chelsea attacker, was running towards Barcelona’s goal, trying to catch a ball passed to him. He was followed closely by Barcelona’s defender Gerard Pique. However, Barcelona’s goal keeper, Víctor Valdés, got to the ball first, and in the process knocked out Pique. He deliver a forceful blow with his hip to Pique’s head. It was not a pretty sight to see. His head made several uncontrolled movements, first from the blow, and then when he fell to the ground unconscious. OK. So what happens now. Me, I am thinking (and tweeting) they should immobilize this guy immediately, put a cervical collar on as a minimum, and surely not let him continue to play. OK. But what do they do. Some guys from Barcelona’s medical team rush to him, start slapping him. OK. His head is flying in all directions. They are not even considering to maybe at least manually stabilize his neck. So he is lying there unconscious for 30 seconds or so. OK. He starts responding, and all is good for these guys. They get him up on his feet, literally do a 5 second exam on him, and yeah man, no worries you are good to go. Get back in there champ.

Take a look at the video.

Is it just me? Or is this totally unacceptable. And sure, what happens next. He starts feeling quite unwell, and 8 minutes after the incident asks for a substitution. The latest news is that he suffered a light concussion and was being kept overnight in a hospital as a precaution after undergoing medical tests. With the medical care he received on the pitch, he is lucky if you ask me.

Here you have this extremely wealthy club in a sport that is turning billions, with players being super stars, earning more money during one minute of play, than you and me in a year. They are the most valuable assets of their clubs, and look how they are treated. OMG, is this for real. My advice to Pique and his colleagues, guys you have tons of money, get yourselves some private medical professionals who will follow you everywhere.

I really thought that these guys learned something, but it seams I was wrong. The guy who knows how medical teams at football matches suck big time, is Petr Cech, who just happened to be defending Chelsea goal when Pique was knocked out. On 14 October 2006, Cech suffered a serious head injury during a game. He and Reading midfielder Stephen Hunt both challenged for the ball inside Chelsea’s penalty area within the first minute of a league match at the Madejski Stadium. Hunt’s right knee hit Cech’s head, leaving him with a depressed skull fracture. Initially unaware of the seriousness of the injury, the doctors later reported that it nearly cost Cech his life, and as a result of the collision, he suffered intense headaches and was warned by his doctor that returning too early could be fatal. After this incident, the South Central Ambulance Service was heavily criticized. Chelsea’s manager at the time, José Mourinho, was critical of the time it took the ambulance to transfer Cech to hospital and Chelsea submitted an official complaint that led to a Premier League and Football Association review, and subsequently led to advances in emergency medical care in the UK.

Take a look at how Cech’s injury occurred, and “brilliant” care he received during the first minutes.

OK. So they learned something in the UK. And what happened to Cech probably had some influence in saving Fabrice Muamba’s life. He suffered cardiac arrest on 17 March 2012 during the first half of an FA Cup quarter-final match between Bolton and Tottenham Hotspur at White Hart Lane. After receiving lengthy attention on the pitch from medical personnel including a consultant cardiologist who was at the game as a fan, Muamba was taken to the specialist coronary care unit at the London Chest Hospital. Muamba had received numerous defibrillator shocks both on the pitch and in the ambulance, but has recovered well, and on 16 April was discharged from the hospital.

Due to a professional team reacting fast, Muamba’s life was saved.

Unfortunately, we humans are really bad at learning for other people’s mistakes. This is what happened tonight in Barcelona, and what happened just some 10 days ago in Italy. On 14 April 2012, while representing Livorno, Piermario Morosini suffered a cardiac arrest and fell to the ground in the 31st minute of the Serie B match against Pescara. The News agency ANSA reported that a city police car was blocking the stadium’s exit for the ambulance for nearly a minute, but a heart specialist said that the delay made no difference. The delay made no difference. Sure, OK that makes it alright. And what about the quality of CPR provided by the medical team?

What can be seen from the available footage, the medical team was very disorganized. There was chaos on the pitch. No chest compressions were performed for a while, no chest compressions as he was put on the stretcher and transferred to the ambulance, no monitoring, no defibrillator attached, no oxygen attached to the bag valve mask, etc.

What strikes me the most is that we are talking about the best clubs and players in the World. Imagine than what is happening in less wealthy countries and in minor leagues. I am afraid to even think about that.

This post was originally published on Tue, 02/28/2012. However, due to issues with web hosting it has been temporarily removed.

A new iOS app I have been working on with my partners for quite some time, has finally been released today in the iTunes store. This iPad specific app is called AED Trainer and can be purchased on sale for 5.99 USD for a limited time period.

AED Trainer app transforms the iPad into a life-like simulator of automatic external defibrillator (AED), allowing the users to get familiar with these life-saving devices. For those who don’t know, AEDs are electronic devices used to deliver electrical shocks to people suffering from cardiac arrest. Electrical shock, also called defibrillation, represents the only therapy for dangerous heart rhythms such as ventricular fibrillation. It is important to note that these devices are not intended to be used by healthcare professionals only. Quite the contrary, they are predominantly aimed at lay rescuers, so you might have seen them hanging on the walls of airports, train stations, stadiums, and other public places. Everyone should know how to use these devices, because cardiac arrest can happen anywhere, anytime and to anyone, and you might just be the one who can save a life. With the AED Trainer app you can experience how a live AED works, try out different scenarios, and be ready to use an actual device in case of a real emergency.

You can learn more about AEDs by watching our “How to use an AED” video.

Download AED Trainer app from the iTunes store.

I just launched a new mini website called TwittER ReaserchER. It is essentially a directory of emergency physicians across the globe who are using Twitter. The project started during research for an article about use of Twitter among emergency physicians. I started tweeting in 2008, and at that time there were only but a few emergency docs out there, but now we managed to identify almost 700 of them. The results of the analysis we performed on their accounts are currently under review in Emergency Medicine Journal. Hopefully the article will be accepted and published soon, so I can share the results with you.

On the website you can find a list of all the emergency physicians we were able to find using Twitter. Each user is represented by his/hers profile picture. If you click on it, you will be taken to the user’s Twitter profile. The list is constantly updating, and if you are an emergency physician using Twitter or know someone who is, please follow @research_er to get included. On this account we also created lists organizing emergency physicians according to the year they started tweeting. You can easily subscribe to these lists.

On the site you can also see the timeline of tweets from all the emergency physicians. It is updating every hour, so you can use it to follow what emergency physicians are saying on Twitter. This way you can follow them, without even being a registered Twitter user, which you should be!

Hope you like the site. I will try to improve it and add more features soon. Of course, your ideas are always welcomed.

Peeps – sorry for the radio silence. Will make it up to you with this: http://ht.ly/4EMV8

Hew (hyū) v.

 
1. To make or shape with or as if with an ax
2. To cut down with an ax

 

“In every block of marble I see a statue as plain as though it stood before me, shaped and perfect in attitude and action. I have only to hew away the rough walls that imprison the lovely apparition to reveal it to the other eyes as mine see it.” – Michaelangelo

An unfinished Michealangelo sculpture.

I just re-read this quote – I think it is a powerful metaphor for any innovator that is out there trying to change the world.They are the ones that can see the fully defined, fully articulated, and fully functional end product within the building blocks that others pass off as mere landscape material. I think this gift of vision – this ability to “see” what others cannot – and the doggedness to stick to the mindless chipping away until others can see it enough to give you the tools you need to finish it off.

We are privileged to be working on a HUGE project right now with a highly innovative company that sees the value of what we are doing and wants to be a part of changing health care. It has been fun to work with them to begin the process of “hewing” away and to literally see the game changing product we have always seen begin to take shape from the dust, the chipped stone, the dirty hands, and the bleeding fingers. The process of discovery and refinement is almost as fun as seeing how the end product will move people.

I am on an email list of Bill DeMarco’s, a reputable industry insider who has written and consulted extensively in the physician group and medical management space. He recently sent me a note about several physician aggregation events in New Jersey.

For some reason it struck a nerve with me . . . which led me to fire off the response below:

Bill,

I thought we already saw this movie?

My question for you . . . besides banding together in some megagroup – what are these physicians doing to actual change the delivery of medicine? ACO is just the latest buzzword excuse to aggregate physicians under a new moniker and a supposed new model.

I am highly suspect that these physicians are doing anything to change the relationship with their patients, to use enabling technology to create team based care, or actually be accountable for the outcomes they produce. What systems are they using to tie themselves together? What financial alignment do they have? What measures are they using to demonstrate superior outcomes? What about the patient experience – 7 minute visits that push pills as the “treatment” won’t get it done in the future.

I think your closing statement, “Representatives from Summit and Optimus were unavailable for comment” says it all.

Am I seeing this the wrong way? Is there anything new about this model this time around? Am I getting old enough to see these things cycle through?

PS – and no, I don’t mean a wolf. The sheep get nervous and band together waiting to get pounced on by wolves.

I had a really great conversation with Shahid Shah, Jenny Laurello and John Moore at Health 2.0 about the bubble that we’re sitting in right now. John Moore’s response to my question, “When do you think the bubble will pop?” was priceless: “Which bubble?” Yes, we might be seeing multiple bubbles in healthcare IT: EHR, HIE, mobile health, etc.

For this blog, I’m most interested in the EHR bubble. Obviously, the bubble in this case is the creation of the $36 billion in EHR stimulus money that’s being handed out thanks to ARRA and the HITECH act. With over 600+ EHR vendors and a limited number of customers (I think there’s about 700,000 physicians in the US), there are going to be quite a few EHR vendors that won’t make it.

With that said, I don’t think the EHR bubble will pop like it has in other industries. In fact, I think the current IT industry bubble is going to be a much bigger problem. What’s amazing to me is how you can make a decent EHR business with only a few hundred doctors. Sure, a few hundred doctors won’t create 10 times return to investors, but those who take a conservative approach to building their EHR company could get by with what I believe is an astoundingly small customer base. Physicians are just that valuable.

Shahid Shah described EHR as a cottage industry and so cottage EHR companies will survive. I’m not exactly sure how he’d described cottage industry, but I think the regional nature of healthcare is definitely an influence on this. I’m sure many could argue that long term this strategy won’t work, but I believe at least for the forseeable future we’re not going to see the EHR bubble pop for a while.

As I think about the EHR companies I know, they all seem to have plenty of cash to make it through meaningful use stage 2 and likely all the way to meaningful use stage 3 at least. We’ll see how the smaller EHR companies do post meaningful use stage 2, but I don’t see any EHR vendors not making it to meaningful use stage 2. They’ll at least make it to MU stage 2. Then, based on their adoption results (or not) we may see a few EHR vendors run out of money.

What do you think? Are we in an EHR bubble? When will the EHR bubble pop? What other healthcare IT bubbles do you see?

Related posts:

1. Top Health Industry Issues of 2011 – “Top 10″ Health IT List Series
2. Would Any Current EMR Users Be Able to Show Meaningful Use?
3. Quote About Current EHR Software

In the comments of a post by Dr. Gregg, someone made a really interesting case for going with an EMR VAR instead of the EMR vendor itself. Of course, this commenter was named “EMRVAR” which probably means they come from a VAR. So, you have to take these comments with a grain of salt, but their comments are worth considering. Here’s the case they made for VARs.

My Advice: Seek out a VAR – Value Added Reseller that cares more about you and your practice then any BIG NAME EMR CORPORATION that only cares about its stock valuation on any given day.

VARS

A VAR is an advocate for your practice – a Var’s many installs weigh more heavily than any one customer that the BIG EMR Corp has.

A VAR deploys technology from several vendors and adapts these products and services to its customer specific needs

A VAR partners with several product manufacturers and service providers. Though partnerships are formed, it is important to realize that a VAR is an independently owned and operated business that is not bound by any one corporation products, services and policies.

A VAR is often located locally to the communities it serves

The VAR model is important in healthcare and the above comments state a pretty good case for the EMR VAR. I find it interesting that in many respects this is the case that small EHR vendors make as well.

What has been your experience with EMR VARs?

Related posts:

1. Physician Case Studies Wanted
2. A Case for EMR Implementation – Multiple Locations
3. Compelling Case for Personal Health Records (PHR)

One movement that I and I’m sure many of you have seen unfolding by HHS and ONC in particular is what Todd Park calls Data Liberacion. As Todd Park has moved to CTO of the US, I expect he’s going to take the data liberation movement beyond healthcare.

The latest addition to the Healthcare Data Liberation movement by ONC is the Health IT Dashboard that was put up by ONC.

Here’s the description of what’s possible for the website:
The Dashboard currently provides summary information about all ONC HITECH grant programs, and detailed data from the Regional Extension Center, and Community College Consortia to Educate Health IT Professionals programs.

Using ONC’s Health IT Dashboard, you can:

• Generate maps of health IT adoption statistics for common groups of health care providers & hospitals,
• Examine the impact of ONC’s Recovery Act grant programs implementation at national and local levels
• Download and analyze the data for your own research projects.

I haven’t had much chance to dig into the data. As I do, I’ll write future posts on what I find. Also, there’s nothing better than crowd sourcing the look at large amounts of data. So, if you’ve found some data that’s interesting, let us know in the comments.

Related posts:

1. Video of Meaningful Use EMR Integrations and MU Dashboard
2. Government Shutdown and Other Governmental Impacts on EMR and Healthcare IT
3. Skepticism Around Meaningful Use and Government Handouts

The following just came across my Google Alerts:Healthcare Analyst Values MMRGlobal Patents at $300-800 Million. This is scary. I’ve seen this company for years; they were one of the pack trying to build personal health records in the mid-2000s, and from what I’ve seen there is nothing in their historic offering that was particularly innovative – except that unlike most of the others running around at the time, they appear to have had some budget to file some patents, and they have now commenced shaking other people down.

Now, I haven’t done a very complete review of their patent holdings, and they may well have some highly innovative, original work there that took a substantial investment to develop and realize. But that’s not the trend, and I’m very concerned that this could be problematic for a lot of small innovators in the personal and clinical health records markets. Software patents have become a real problem across a variety of domains, but so far HIT seems to have avoided the worst of it. I suspect that this is in part because of industry’s long history – most of the core capabilities were introduced long enough ago that any patents would have expired. There’s a ton of prior art: you can track a lot of personal health monitoring to 1994′s Guardian Angel Manifesto. But that’s expensive to litigate when the trolls come out from under the bridge.

As it stands, I’m looking for defensive patent structures for my own start-up so that we have some chits to trade if someone comes knocking. And that’s a shame – I have better things to do with my time.

Just read a nice summary from OpenView on hiring your first sales manager. This is, far and away, one of the most daunting things that any technically minded startup CEO faces. If you come from an engineering or science background, it’s easy to think of the sales team as, if not actually an enemy, as something a little bit alien. I know a lot of engineers who simply don’t get on people in sales – they regard them either as ineffective suit-fillers who can’t do “work that matters” or as the latest embodiment of the obnoxious popular kid from high school.

Some companies try to get around this by making sales people out of people who aren’t naturally sales people. In the Healthcare IT space, that’s often former nurses or physicians who want a career change. In software, it’s often software engineers. There’s potential in all three groups, but it takes a certain type.

If all goes well, I’ll be going through this process again in the near future. If so, I’ll post what I learn.

Knowing how to code is a really useful skill for anybody in business. For an entrepreneur, it means you can validate your high-tech startup idea without having to out and recruit a CTO or spend a lot of money on an external software development shop. But even if you’re running a pizza place, a little bit of coding experience can save you a lot of time when you’re playing with Excel spreadsheets late at night trying to figure out how much money all that fancy pepperoni is costing you.  Most people are in the middle. I have a lot of friends who went into management consulting – the ones who know how to write little bits of software to help them do their jobs tend to get a lot more sleep at night.

The other reason to learn programming – even a little bit of programming – is that it makes the whole process of interacting with technology a lot less scary. Computers are black boxes, and people don’t trust black boxes.

So I thought CodeAcademy was pretty cool. It’s a web site that takes you through some simple programming exercises in JavaScript, which is one of the most common programming languages on the web. In half an hour you can go from no experience at all to writing simple programs. They don’t do that much, and to solve real problems you’ll have to do more. But it’s a nice way to start out – and even if the student doesn’t go any further they’ll benefit from a more visceral understanding of how computers work. In the best case, it will teach them to recognize the kinds of patterns that can be solved with a little code.

Having written that, I suppose I should consider the opposite extreme. Just because you can write simple programs after half an hour of interactive lessons doesn’t mean that software development is either easy or low-value. It’s not. A top-tier software engineer took thousands of hours to get that way.

I’ve come across few articles recently that really validate the notion that the success of healthcare IT is really in the eye of the beholder, or in some cases, the editorialized results of a study.

Take, for example, the following headlines:

“EHR Use Not Linked to Improved Diabetes Care Quality, Study Finds”
and
“App Improves Diabetes Management Among Teenagers, Study Finds”

I find it hard to believe that if formally connected, the second study couldn’t somehow influence the first. In other words, if a mobile health app can improve diabetes management among teenagers, shouldn’t whatever data that app is capturing transmit successfully to the teen patients’ EHRs for easy access by their doctors? And then couldn’t that doctor digest that information, picking out patterns in the patient’s behavior that is either positively or negatively impacting their diabetic condition and overall health, to better inform care protocols?

I’m taking big leaps of logic here, since the first study found that not only was there no correlation between the use of an EHR and “increased adherence to clinical guidelines for care processes and treatments,” but there was actually a “higher probability of meeting certain targets for blood pressure and A lc levels after two years” at practices without such systems. (Seems like these outcomes might be due more to end-user experience than the technology itself.)

The second study doesn’t even mention EHRs, but I wonder how many of the 20 teens participating in the study see doctors who have this type of technology, how many of those doctors know their patients are participating in the study (all I’d assume), and how many are feeding the app’s info into an EHR.

Surely if a smartphone app is helping a diabetic teenager better adhere to medication regimens, then the EHR their doctor could potentially be using would somehow tie in to better clinical outcomes. Another study to start, perhaps?

The second set of headlines that gives me pause (and kinda makes me chuckle) includes:

“Physician Use of Tablets has Nearly Doubled Since 2011”
and
“Not all Doctors and Nurses are Happy with an iPad in the Hospital Setting”

Neither headline surprises me. We all know that adoption of mobile health tools is growing, if not by leaps and bounds then at least steadily. It would make sense that providers are adopting tablets in relation to this. Every technology has its detractors, so of course not everyone is going to be happy with how an iPad works in a clinical setting, just as not every provider is going to want to install an EHR. I do wonder, though, how the same set of users mentioned in the second article would rate a different kind of tablet if given the opportunity to use one.

I find the first sentence to be kind of hard to believe: “It looks as if most doctors and nurses would rather not touch the iPad at work (or deal with any other kind of tablet computing).” If “most” doctors and nurses would rather have nothing to do with tablets at work, than how can physician use of tablets have doubled since last year?

So you see, the “success” of healthcare IT seems to depend on whose writing about it. I have a feeling the American Forest and Paper Association might be behind the very first one.

Related posts:

1. Will Rip and Replace EHR Software Ever Be a Thing of the Past?
2. Emdeon Gets in the Holiday Spirit with Donation of EHR Technology
3. From the Trenches of Healthcare IT Education

I’m in Boston enjoying meeting with a lot of really smart people at Health 2.0. As usual, the biggest value of the conference is the people you meet and the hallway conversations you have with those people. I’ll certainly be doing posts over the next couple weeks related to those conversations.

The other highlight of Health 2.0 was hearing Jonathan Bush speak. He was in true Jonathan Bush form and he’s great because you can guarantee that he’ll never give the same speech twice. As one person said in the hallway, the connection between him thinking it and him saying it is very short. It’s so short that it has no filter. My biggest complaint with Jonathan Bush’s talk was that they only gave him 20 minutes on stage. Not nearly enough.

For those who couldn’t make it, here’s the main points that Jonathan Bush provided:
1. “Don’t bite off more than you can chew.”
2. “You need your partner’s ‘id’ as well as their signature.”
3. “Culture trumps capability.”

This is all really good advice for healthcare startup companies. One other thought from Jonathan Bush:

.@Jonathan_Bush compares entrepreneurial survival to paramedics’ attention to the ABCs…focus on first things first. #health2con #EMS

— Carissa O’Brien (@CarissaO) May 15, 2012

Here are some other good takeaways from Health 2.0 Boston that were tweeted out:

Steve Krein: Introductions are easy, being prepared for the meeting and what follows is hard #health2con

— Matthew Holt (@boltyboy) May 15, 2012

Very good advice and appropriate at Health 2.0 Boston since the focus of it is about partnerships.

The core problem is “uncompensated care.”#health2con

— EMR, EHR and HIT(@ehrandhit) May 15, 2012

There’s a compelling story if you look at how much uncompensated care physicians provide.

Related posts:

1. It’s Official – I’m Attending the Connected Health Symposium in Boston
2. Digital Health Summit at CES and Stop SOPA
3. A National Universal Health Record (UHR) Database – Doable Any Time Soon?

Over at healthaffairs.org, there was a super interesting brief on Affordable Care Act and its forthcoming changes regarding employee health. Starting in 2014, employers will be able to offer incentives to employees regarding their enrollment in employee wellness programs. Employers can offer incentives such as monetary rewards for positive employee behavior like enrolling in a smoking cessation program, or joining a gym at discounted rates. Or these can work like the proverbial stick, by imposing penalties on non-compliant employees, e.g. increasing the cost of participating in an employer health plan by $1000 for employees who say they have smoked in the last year.

Now all those good components of the ACA will still be applicable i.e insurance companies will not be able to refuse patients based on prior medical history. But I can’t help but notice the irony of the ACA being used to discriminate between a healthy employee and a sick one.

One of the examples cited in the brief is that it will be legal for an employer to offer a health plan to employees who fulfil certain wellness criteria such as enrolling in a gym in addition to the other health plan options available to its other employees. The cost of the other health plan options to a truly unwell employee could well be so exorbitant as to make it impossible for him/her to enroll in it. Options for such employees could be to enroll through a spouse’s plan or purchase private insurance through the health information exchanges. The brief says that there are plugs for these sorts of employer excesses, such as companies with over 50 employees will be penalized even if one employee enrolls in a subsidized state insurance program in lieu of the company sponsored one.

I’m also wondering if there will be any kind of guidelines for companies to design their incentive/penalty programs. Health and wellness are incredibly nuanced issues. For every person who can exercise a half hour a day and lose a pound a week, there are those who seemingly subsist on air and water and barely make a dent in their BMI. Genes determine plenty of factors in a person’s helath profile, including weight, propensity to develop certain conditions and so on. It makes me wonder if we’re oversimplifying things by gauging employee wellness based on criteria such as gym enrollment.

Plus what if you have lots of people like me who might enroll in a gym and never see the inside of it beyond the first few days? Simple enrollment might not be enough. But, to my mind at least, tying enrollment to outcomes has the unfortunate whiff of a mini nanny state in the making. Who wants to be the person at the company weigh-in whose BMI has come down by .1 while the muscled, rippled company health club employee looks at you quizzically? Not me.

I also worry about the unwell employee who feels pressured into signing up for risky activities (from his/her health perspective), simply in order to get the rewards offered or to avoid the penalties. S/he might have something truly tangible to lose both ways.

I would love to see how ACA transforms in the next couple of years but right now I think I have way too many unanswered questions.

Related posts:

1. iPad in Health Care
2. Health Care IT 2011 Predictions
3. Health Care IT at CES

1. Every Medical Practice Needs a CIO
2. AMA publishes a FAQ on encryption
3. Six Healthcare Data Breaches That Might Make Security Pros Sick

1. Every Medical Practice Needs a CIO
2. Network Costs of an EMR Implementation
3. The dangers of cloud computing

1. Every Medical Practice Needs a CIO
2. HIPAA Security Rule Implementation
3. HIPAA Security Rule Risk Analysis and Management

The Federation of State Medical Boards has released Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice. It addressed the physician-patient relationship, professional and ethical standards and provides recommendations for state medical boards to consider in educating their licensees on the proper use of social media and social networking websites.

The following recommendations are also included:

• Physicians should only have online interaction with patients when discussing the patient’s medical treatment within the physician-patient relationship – and these interactions should never occur on personal social networking or social media websites.
• Patient privacy and confidentiality must be protected at all times, especially on social media and social networking websites. Although physicians may discuss their experiences in non-clinical settings, they should never provide any information that could be used to identify patients.
• Physicians should be aware that any information they post on a social networking site may be disseminated to a larger audience, and that what they say may be taken out of context or remain publicly available online in perpetuity.

One study in JAMA found that 92% of state medical boards in the United States have received reports of violations of online professionalism, so this guidance is really a bit overdue.  But, I'm glad both the boards and licensed physicians now have some clearly defined expectations and guidelines for moving forward.

For all of my nursing followers, similar guidance is also available in a previous post.

If you are like me and feel we need to start educating consumers on the power of telemedicine, then please share this video.  It was created by my friends at @CTELTweets, so let them know what you think!

I'm currently working with a healthcare system and one piece of the project is to incorporate social media into the patient experience.  There are truly innovative opportunities to apply the technologies to solve operational, care and support challenges across the continuum from the worried well through pre-treatment, treatment and post-treatment.  It has been exciting to talk with staff about their specific needs and matching technologies that will help accomplish the job.

I've shared examples of these over the years in my blog posts, book and articles (see left column).  Some of my early favorites are outlined as my best practice examples.  All it takes is a little imagination, thinking thought the purpose, goals and processes and building in the appropriate management structure.

Once you get beyond the initial thinking and planning, consider these 4 social media strategies to build patient loyalty by engaging consumers in two-way conversations. 

• Incorporate humor
• Integrate your social media channels
• Keep the budget low
• Tie Social Media to Service Lines

From the MIT press release

Researchers at MIT and two Boston hospitals provide early evidence that a simple, unobtrusive wrist sensor could gauge the severity of epileptic seizures as accurately as electroencephalograms (EEGs) do — but without the ungainly scalp electrodes and electrical leads. The device could make it possible to collect clinically useful data from epilepsy patients as they go about their daily lives, rather than requiring them to come to the hospital for observation. And if early results are borne out, it could even alert patients when their seizures are severe enough that they need to seek immediate medical attention.

Rosalind Picard, a professor of media arts and sciences at MIT, and her group originally designed the sensors to gauge the emotional states of children with autism, whose outward behavior can be at odds with what they’re feeling. The sensor measures the electrical conductance of the skin, an indicator of the state of the sympathetic nervous system, which controls the human fight-or-flight response.

In a study conducted at Children’s Hospital Boston, the research team — Picard, her student Ming-Zher Poh, neurologist Tobias Loddenkemper and four colleagues from MIT, Children’s Hospital and Brigham and Women’s Hospital — discovered that the higher a patient’s skin conductance during a seizure, the longer it took for the patient’s brain to resume the neural oscillations known as brain waves, which EEG measures.

At least one clinical study has shown a correlation between the duration of brain-wave suppression after seizures and the incidence of sudden unexplained death in epilepsy (SUDEP), a condition that claims thousands of lives each year in the United States alone. With SUDEP, death can occur hours after a seizure.

Currently, patients might use a range of criteria to determine whether a seizure is severe enough to warrant immediate medical attention. One of them is duration. But during the study at Children’s Hospital, Picard says, “what we found was that this severity measure had nothing to do with the length of the seizure.” Ultimately, data from wrist sensors could provide crucial information to patients deciding whether to roll over and go back to sleep or get to the emergency room.

Read the full press release

(From the CFP website)

Sensors, such as wireless EEG caps, that provide us with information about the brain activity are becoming available for use outside the medical domain. As in the case of physiological sensors information derived from these sensors can be used – as an information source for interpreting the user’s activity and intentions. For example, a user can use his or her brain activity to issue commands by using motor imagery. But this control-oriented interaction is unreliable and inefficient compared to other available interaction modalities. Moreover a user needs to behave as almost paralyzed (sit completely still) to generate artifact-free brain activity which can be recognized by the Brain-Computer Interface (BCI).

Of course BCI systems are improving in various ways; improved sensors, better recognition techniques, software that is more usable, natural, and context aware, hybridization with physiological sensors and other communication systems. New applications arise at the horizon and are explored, such as motor recovery and entertainment. Testing and validation with target users in home settings is becoming more common. These and other developments are making BCIs increasingly practical for conventional users (persons with severe motor disabilities) as well as non-disabled users. But despite this progress BCIs remain, as a control interface, quite limited in real world settings. BCIs are slow and unreliable, particularly over extended periods with target users. BCIs require expert assistance in many ways; a typical end user today needs help to identify, buy, setup, configure, maintain, repair and upgrade the BCI. User-centered design is underappreciated, with BCIs meeting the goals and abilities of the designer rather than user. Integration in the daily lives of people is just beginning. One of the reasons why this integration is problematic is due to view point of BCI as control device; mainly due to the origin of BCI as a control mechanism for severely physical disabled people.

In this challenge (organised within the framework of the Call for Challenges at ICMI 2012), we propose to change this view point and therefore consider BCI as an intelligent sensor, similar to a microphone or camera, which can be used in multimodal interaction. A typical example is the use of BCI in sonification of brain signals is the exposition Staalhemel created by Christoph de Boeck. Staalhemel is an interactive installation with 80 steel segments suspended over the visitor’s head as he walks through the space. Tiny hammers tap rhythmic patterns on the steel plates, activated by the brainwaves of the visitor who wears a portable BCI (EEG scanner). Thus, visitors are directly interacting with their surroundings, in this case a artistic installation.

The main challenges to research and develop BCIs as intelligent sensors include but are not limited to:

• How could BCIs as intelligent sensors be integrated in multimodal HCI, HRI and HHI applications alongside other modes of input control?
• What constitutes appropriate categories of adaptation (to challenge, to help, to promote positive emotion) in response to physiological data?
• What are the added benefits of this approach with respect to user experience of HCI, HRI and HHI with respect to performance, safety and health?
• How to present the state of the user in the context of HCI or HRI (representation to a machine) compared to HHI (representation to the self or another person)?
• How to design systems that promote trust in the system and protect the privacy of the user?
• What constitutes opportune support for BCI based intelligent sensor? In other words, how can the interface adapt to the user information such that the user feels supported rather than distracted?
• What is the user experience of HCI, HRI and HHI enhanced through BCIs as intelligent sensors?
• What are the ethical, legal and societal implications of such technologies? And how can we address these issues timely?

We solicit papers, demonstrators, videos or design descriptions of possible demonstrators that address the above challenges. Demonstrators and videos should be accompanied by a paper explaining the design. Descriptions of possible demonstrators can be presented through a poster.
Accepted papers will be included in the ICMI conference proceedings, which will be published by ACM as part of their series of International Conference Proceedings. As such the ICMI proceedings will have an ISBN number assigned to it and all papers will have a unique DOI and URL assigned to them. Moreover, all accepted papers will be included in the ACM digital library.

Deadline for submission: June 15, 2012
Notification of acceptance: July 7, 2012
Final paper: August 15, 2102

Researchers at Federal Institute of Technology in Lausanne, Switzerland (EPFL), have successfully demonstrated a robot controlled by the mind of a partially quadriplegic patient in a hospital 62 miles away. The EPFL brain-computer interface system does not require invasive neural implants in the brain, since it is based on a special EEG cap fitted with electrodes that record the patient’s neural signals. The task of the patient is to imagine moving his paralyzed fingers, and this input is than translated by the BCI system into command for the robot.

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Recently, I was in discussion with couple of my friends who are Clinicians & the topic of ‘healthcare IT in India’ popped up as it has been my habit to raise this topic in such forums to get ideas and feedback. This time to my surprise everyone around the table were really interested in this topic! which was not so in some of my earlier discussions with them. Interesting, I started probing further and I could clearly make out the increased awareness of Healthcare IT and its benefits in their practice.

Some of them had started using some or the other IT products and were inching towards more advanced solutions. I am just sharing 6 excerpts from the discussion.

Computer education:  As usual the team felt that the inhibition for adopting IT systems is largely because of lack of computer education in medical fraternity however, they also felt that the newer generation is embracing it fast & cross industry partnerships could help in improving the situation.

System usability: No surprise!, usability was a major concern. You blame it to either their experience level in system usage or bad designs of the products in either case it was found to be an issue which is bothering them.  May be system designers should do bit more user analysis and come out with creative usable products which would provide them easy to use UIs.

Solutions in the market: Interesting to find that they still feel that they are not many products in the market which are path breaking and fit their purpose, there are many big players offering their global products with little variations which are actually too far from what they need and new startups seems to be underestimating their needs.

Affordability: No doubt it is a price sensitive market, They feel it is little expensive to go for IT solutions however, in my opinion certainly people have realized what IT can do to their practice but there is a need to justify the quantum of value addition & also providers should think of different billing models to increase adoption.

Pervasiveness: It’s not a desktop bound job! They need solutions which are pervasive enough to move around with them and assist as and when they want, may be mobile or tablet based solutions could be an answer for this.

Fear of losing data: Somewhere in the corner they also expressed concern towards data and its maintenance. The fear is quite apparent because they are used to records and reports which are in more tangible physical forms but I am sure that confidence building and demonstration of  technology usage in other industries and also in healthcare in other countries would bring in more confidence.

These points may be views from a small group of people but sure points to look further. Please feel free to add your feedback and experience in below comment box.

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